Transcript
Atlas $1000 Atlas $3000 Atlas $6400
2021 Formulary
(List of covered drugs)
For current information on the GenericsAdvantageRx Drug List, visit healthpartners.com/pharmacy.
Effective: October 1, 2021
©2021 HealthPartners
What’s the GenericsAdvantageRx drug list?
This is the list of medicines (sometimes called a formulary) covered by your health plan. The drug list is reviewed by a
team of experts every three months for new medicines, safety alerts and other updates.
Who decides what’s on the drug list?
The HealthPartners Pharmacy and Therapeutics Committee manage the list. This team of experts focuses on safety,
effectiveness and affordability. Visit healthpartners.com/pharmacy for more information.
How do you use the drug list?
The medicines are listed in alphabetical order by type of medicine starting on page 4.
Generic medicines are in lowercase italics (e.g., cephalexin). These medicines are safe and effective but cost less than brand
medicines.
Brand medicines are in ALL CAPS (e.g., KEFLEX) and are more costly than generic medicines.
The Tier is used to determine how much a medicine will cost you. For exact cost information,
• Find the tier status for your medicine.
• Review your Summary of Plan Benefits or contract for the copay or coinsurance for that Tier Status. Or,
• Log on to your myHealthPartners account to check your pharmacy benefits.
o Tier 1 – Formulary Low Cost Generics o Tier 2 – Formulary High Cost Generics
o Tier 3 – Formulary Brands
o Tier 4 – Non-Formulary Generics & Brands
(Non-Formulary medicines are not listed in this document)
o Tier 5 – Specialty Generics & Brands
What’s a Specialty Medicine?
Specialty medicines are usually prescribed by doctors whose focus is on the treatment of chronic and complex diseases.
These medicines usually require more management, have a high price and aren’t always stocked at retail pharmacies.
Prescriptions for these medicines must be filled at a specialty pharmacy and are often covered at a different benefit than
non-specialty medicines. Log on to your myHealthPartners account and click on My plan benefits on the Medical Plan
tab to check your benefits for specialty medicines.
What do the abbreviations under Limits & Restrictions mean?
Special information about the medicine you’re searching for. The abbreviations let you know there might be a special program
or rule for the medicine. Use this key to help you navigate the drug list:
• PA - Prior Authorization Required
• ST - Step Therapy Required
• AL1 - Age Limit
• AQ1 – Age Quantity Limit
• QL - Quantity Limit
• SC - Smoking Cessation Benefit
• WL - Weight Loss Benefit
• ONC - Oncology Benefit
• TD - Trial Drug Program
• S – Specialty
Why do you need prior authorization (PA) for some medicines? Even though some medicines are on the drug list, they
need to meet the HealthPartners prior authorization criteria in order for the medicine to be covered by your
pharmacy benefits.
What’s Step Therapy (ST)? Some medicines are on the drug list, but you need to try
one or more other medicines first. HealthPartners
covers a medicine with step therapy, if you've already
tried the other medicine(s). If you haven't, you or your doctor will need to get approval from HealthPartners
before the medicine will be covered by your lowest
brand, generic or specialty copay or coinsurance.
What’s an Age Limit (AL1)? An age edit means some medicines are only covered if
you’re within a specific age range. If you're not in the
approved age range, you or your doctor will need to
request approval from HealthPartners for your
medicine to be covered.
What’s an Age Quantity Limit (AQ1)?
An age quantity limit means some medicines have a quantity limit that only applies to a specific age range. If
you're not in the approved age range, you or your
doctor will need to request approval from
HealthPartners for your medicine to be covered.
What’s a Quantity Limit (QL)? This means HealthPartners limits the amount of the
medicine you'll get each time you fill your prescription.
The quantity limit may be less than the day supply listed in your contract or Summary Plan Description.
What’s the Trial Drug Program (TD)? The trial drug program is for new prescriptions for
certain medicines that may not be well tolerated due
to:
• Side effects
• High cost
• High potential for waste
Your first 6 fills of a trial drug may be limited to less
than a month supply. If the medicine works well, you’ll
get the rest of your month supply. If a copay applies to
the medicine, you’ll pay no more than one copay for
each one month supply.
What’s the Weight Loss Benefit (WL)? This type of medicine may have limits on the amount
you get or may not be covered under all plans. Log on to
your myHealthPartners account and click on My plan
benefits on the Medical Plan tab to check your benefits
for weight loss. Weight Loss medicines are listed on the
drug list under the Weight Loss medicine category.
What’s the Oncology Benefit (ONC)? These are oncology (cancer) medicines that must be filled at a specialty pharmacy, but you’re only responsible for your regular generic or brand pharmacy copay or coinsurance.
The HealthPartners family of health plans is underwritten and/or administered by HealthPartners, Inc., Group Health, Inc., HealthPartners Insurance Company or HealthPartners Administrators, Inc. Fully insured Wisconsin plans are underwritten by HealthPartners Insurance Company. (10/21) ©2021 HealthPartners
LIST OF COVERED PRESCRIPTION MEDICATIONSPRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ALPHA-ADRENERGIC BLOCKING AGENT(SYMPATH)NON-SEL.ALPHA-ADRENERGIC BLOCKING AGENTS
ergoloid mesylates 2 PA
phenoxybenzamine hcl 2 PA
SELECTIVE ALPHA-1-ADRENERGIC BLOCK.AGENTalfuzosin hcl er 2
tamsulosin hcl 1
ANALGESICS AND ANTIPYRETICSANALGESICS AND ANTIPYRETICS, MISC.
butalb-acetamin-caff 50-325-40 2 QL 6 TABS / 1 DAY
butalbital-acetaminophn 50-325 2 QL 6 TABS / 1 DAY
TENCON 2 QL 6 TABS / 1 DAY
ZEBUTAL 2 QL 6 CAPS / 1 DAY
OPIATE AGONISTS
acetamin-codein 300-30 mg/12.5 2 AQ1 At least 12 yrs old;60 / 1 DAY
acetaminop-codeine 120-12 mg/5 1 AQ1 At least 12 yrs old;60 / 1 day(s)
acetaminophen-codeine (#2 tablet, #3 tablet, #4 tablet) 2 AQ1 At least 12 yrs old; 8/ 1 DAY
codeine sulfate 2 AQ1 At least 12 yrs old; 8/ 1 DAY
ENDOCET 10-325 MG TABLET 2 QL 5 TABS / 1 DAY
ENDOCET 5-325 TABLET 2 QL 8 TABS / 1 DAY
ENDOCET 7.5-325 MG TABLET 2 QL 7 TABS / 1 DAY
fentanyl (12 mcg/hr patch, 25 mcg/hr patch, 50 mcg/hrpatch, 75 mcg/hr patch, 100 mcg/hr patch)
2 PA
hydrocodone-acetaminophen (5-325 mg, 7.5-325, 10-325mg)
2 QL 8 TABS / 1 DAY
PAGE 1 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONShydrocodone-acetaminophen (hydrocodone-acetamin2.5-108/5, hydrocodone-acetamin 5-217/10,hydrocodone-acetamn 7.5-325/15)
2 QL 120 ML / 1 DAY
hydrocodone-ibuprofen 7.5-200 2 QL 8 TABS / 1 DAY
hydromorphone 2 mg tablet 2 QL 8 TABS / 1 DAY
hydromorphone 3 mg suppos 2 QL 8 SUPP / 1 DAY
hydromorphone 4 mg tablet 2 QL 5 TABS / 1 DAY
hydromorphone 8 mg tablet 2 QL 2 TABS / 1 DAY
hydromorphone hcl (1 mg/ml solution, 5 mg/5 ml soln) 2 QL 20 ML / 1 DAY
LORCET 2 QL 8 TABS / 1 DAY
LORCET HD 2 QL 8 TABS / 1 DAY
LORCET PLUS 2 QL 8 TABS / 1 DAY
methadone hcl (5 mg/5 ml solution, hcl 5 mg tablet, 10mg/5 ml solution, 10 mg/ml oral conc, hcl 10 mg tablet,40 mg tablet dispr)
2 PA
METHADONE INTENSOL 2 PA
METHADOSE 40 MG TABLET DISPR 2 PA
morphine sulf 10 mg/5 ml soln 2 QL 30 ML / 1 DAY
morphine sulf 100 mg/5 ml conc 2 QL 4 ML / 1 DAY
morphine sulf 20 mg/5 ml soln 2 QL 20 ML / 1 DAY
morphine sulfate (5 mg suppos, 10 mg suppos, 20 mgsuppos, 30 mg suppos)
2 QL 8 SUPP / 1 DAY
morphine sulfate er (er 15 mg tablet, er 30 mg tablet, er60 mg tablet, er 100 mg tablet, er 200 mg tablet)
2 PA
morphine sulfate ir 15 mg tab 2 QL 5 TABS / 1 DAY
MORPHINE SULFATE IR 15 MG TAB (BRAND) 3 QL 5 TABS / 1 DAY
morphine sulfate ir 30 mg tab 2 QL 2 TABS / 1 DAY
MORPHINE SULFATE IR 30 MG TAB (BRAND) 3 QL 2 TABS / 1 DAY
PAGE 2 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
oxycodone hcl 10 mg tablet 2 QL 5 TABS / 1 DAY
oxycodone hcl 100 mg/5 ml conc 2 QL 2 ML / 1 DAY
oxycodone hcl 15 mg tablet 2 QL 3 TABS / 1 DAY
oxycodone hcl 20 mg tablet 2 QL 2 TABS / 1 DAY
oxycodone hcl 30 mg tablet 2 PA
oxycodone hcl 5 mg capsule 2 QL 8 CAPS / 1 DAY
oxycodone hcl 5 mg tablet 2 QL 8 TABS / 1 DAY
oxycodone hcl 5 mg/5 ml soln 1 QL 40 ML / 1 DAY
oxycodone hcl er (er 10 mg tablet, er 15 mg tablet, er 20mg tablet)
2 PA
oxycodone hcl er (er 30 mg tablet, er 40 mg tablet, er 60mg tablet, er 80 mg tablet)
1 PA
oxycodone hcl-aspirin 2 QL 8 TABS / 1 DAY
oxycodone-acetaminophen 10-325 2 QL 5 TABS / 1 DAY
oxycodone-acetaminophen 5-325 2 QL 8 TABS / 1 DAY
oxycodone-acetaminophn 7.5-325 2 QL 7 TABS / 1 DAY
OXYCONTIN 3 PA
tramadol hcl 50 mg tablet 1 AQ1 At least 12 yrs old; 8/ 1 DAY
tramadol hcl-acetaminophen 2PA
AQ1 At least 12 yrs old; 8/ 1 DAY
OPIATE PARTIAL AGONISTS
buprenorphine 2 PA
buprenorphine-nalox 12-3mg flm 2 QL 2 FILMS / 1 DAY
buprenorphine-naloxone (2-0.5mg fm, 4-1mg film, 8-2mgfilm)
2 QL 3 FILMS / 1 DAY
buprenorphine-naloxone (2-0.5mg tb, 8-2 mg tab) 2 QL 3 TABS / 1 DAY
PAGE 3 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANOREXIGENIC AGENTSAMPHETAMINE DERIVATIVES
LOMAIRA 2QL 3 TABS / 1 DAY
WL Weight Loss
phentermine 15 mg capsule 2QL 2 CAPS / 1 DAY
WL Weight Loss
phentermine 37.5 mg tablet 2QL 1 TAB / 1 DAY
WL Weight Loss
phentermine hcl (30 mg capsule, 37.5 mg capsule) 2QL 1 CAP / 1 DAY
WL Weight Loss
ANOREXIGENICS;RESPIRATORY,CNS STIMULANTSAMPHETAMINES
ADDERALL XR 2 QL 2 CAPS / 1 DAY
dextroamp-amphetamin 15 mg tab (generic adderall) 2 QL 3 TABS / 1 DAY
dextroamp-amphetamin 20 mg tab (generic adderall) 2 QL 3 TABS / 1 DAY
dextroamp-amphetamin 30 mg tab 2 QL 2 TABS / 1 DAY
dextroamphetamine sulfate (5 mg tab, 10 mg tab) 2 QL 4 TABS / 1 DAY
dextroamphetamine sulfate er 2 QL 4 CAPS / 1 DAY
dextroamphetamine-amphetamine (dextroamp-amphetam 7.5 mg tab, dextroamp-amphetam 12.5 mgtab, dextroamp-amphetamin 10 mg tab, dextroamp-amphetamine 5 mg tab)
2 QL 3 TABS / 1 DAY
VYVANSE (10 MG CAPSULE, 20 MG CAPSULE, 30 MGCAPSULE)
3 QL 2 CAPS / 1 DAY
VYVANSE (10 MG TABLET, 20 MG TABLET, 30 MG TABLET) 3 QL 2 CHEW TABS / 1DAY
VYVANSE (40 MG CAPSULE, 50 MG CAPSULE, 60 MGCAPSULE, 70 MG CAPSULE)
3 QL 1 CAP / 1 DAY
VYVANSE (40 MG TABLET, 50 MG TABLET, 60 MG TABLET) 3 QL 1 CHEW TAB / 1 DAY
ZENZEDI (5 MG TABLET, 10 MG TABLET) 2 QL 4 TABS / 1 DAY
PAGE 4 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RESPIRATORY AND CNS STIMULANTSCONCERTA (ER 18 MG TABLET, ER 27 MG TABLET, ER 36MG TABLET)
2 QL 2 TABS / 1 DAY
CONCERTA ER 54 MG TABLET 2 QL 1 TAB / 1 DAY
dexmethylphenidate hcl 2 QL 2 TABS / 1 DAY
dexmethylphenidate hcl er (er 25 mg cp, er 30 mg cp, er35 mg cp, er 40 mg cp)
2 QL 1 CAP / 1 DAY
dexmethylphenidate hcl er (er 5 mg cap, er 10 mg cp, er15 mg cp, er 20 mg cp)
2 QL 2 CAPS / 1 DAY
METADATE ER 2 QL 3 TABS / 1 DAY
methylphenidate er (la) (10mg cp, 20mg cp, 30mg cp) 2 QL 2 CAPS / 1 DAY
methylphenidate er 10 mg tab 2 QL 4 TABS / 1 DAY
methylphenidate er 20 mg tab 2 QL 3 TABS / 1 DAY
methylphenidate er(la) 40mg cp 2 QL 1 CAP / 1 DAY
methylphenidate hcl (5 mg tablet, 10 mg tablet, 20 mgtablet)
2 QL 3 TABS / 1 DAY
methylphenidate hcl cd (10 mg cap, 20 mg cap, 30 mgcap)
2 QL 2 CAPS / 1 DAY
methylphenidate hcl cd (40 mg cap, 50 mg cap, 60 mgcap)
2 QL 1 CAP / 1 DAY
methylphenidate hcl er (cd) (10mg cp, 20mg cp, 30mg cp) 2 QL 2 CAPS / 1 DAY
methylphenidate hcl er (cd) (40mg cp, 50mg cp, 60mg cp) 2 QL 1 CAP / 1 DAY
methylphenidate la (10 mg cap, 20 mg cap, 30 mg cap) 2 QL 2 CAPS / 1 DAY
methylphenidate la (40 mg cap, 60 mg cap) 2 QL 1 CAP / 1 DAY
QUILLICHEW ER 20 MG CHEW TAB 3 QL 3 CHEW TABS / 1DAY
QUILLICHEW ER 30 MG CHEW TAB 3 QL 2 CHEW TABS / 1DAY
QUILLICHEW ER 40 MG CHEW TAB 3 QL 1 CHEW TAB / 1 DAY
QUILLIVANT XR 3 QL 6 ML / 1 DAY
PAGE 5 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
WAKEFULNESS-PROMOTING AGENTS
armodafinil (150 mg tablet, 200 mg tablet, 250 mg tablet) 2 QL 1 TAB / 1 DAY
armodafinil 50 mg tablet 2 QL 2 TABS / 1 DAY
modafinil 2 QL 2 TABS / 1 DAY
SUNOSI 3QL 1 TAB / 1 DAY
PA
WAKIX 5PA
S
ANTI-INFECTIVE AGENTSANTHELMINTICS
albendazole 2 PA
ivermectin 3 mg tablet 2
praziquantel 2
URINARY ANTI-INFECTIVES
fosfomycin tromethamine 2 QL 1 PACKET / RX
nitrofurantoin (25 mg/5 ml susp, mcr 25 mg cap) 2 AL1 Up to 12 yrs old
nitrofurantoin (50 mg cap, 100 mg cap) 2
nitrofurantoin mono-macro 2
trimethoprim 1
ANTI-INFECTIVES (EENT)ANTIBACTERIALS (EENT)
bacitracin 500 unit/gm ophth 2
bacitracin-polymyxin 2
BESIVANCE 3 PA
BLEPHAMIDE S.O.P. 3
CILOXAN 0.3% OINTMENT 3
CIPRO HC 3
ciprofloxacin 0.3% eye drop 1
PAGE 6 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ciprofloxacin-dexamethasone 2
doxycycline hyclate 20 mg tab 1
erythromycin 0.5% eye ointment 2
moxifloxacin 0.5% eye drops 1
neomyc-polym-dexamet eye ointm 2
neomycin-bacitracin-polymyxin 2
neomycin-polymyxin-gramicidin 1
neomycin-polymyxin-hc ear susp 2
neomycin-polymyxin-hydrocort 2
ofloxacin (ear drops, eye drops) 2
polymyxin b sul-trimethoprim 2
sulfacetamide sodium (drops, ointment) 2
sulfacetamide-prednisolone 2
TOBRADEX EYE OINTMENT 3
tobramycin 0.3% eye drop 2
tobramycin-dexamethasone 2
TOBREX 0.3% EYE OINTMENT 3
ANTIVIRALS (EENT)trifluridine 2
ZIRGAN 3
EENT ANTI-INFECTIVES, MISCELLANEOUSacetic acid 2% ear solution 2
chlorhexidine gluconate 1
PAROEX 2
PERIOGARD 2
ANTI-INFECTIVES (SKIN, MUCOUS MEMBRANE)ANTIBACTERIALS (SKIN, MUCOUS MEMBRANE)
CLEOCIN 100 MG VAGINAL OVULE 3
clind ph-benzoyl perox 1.2-5% 2
PAGE 7 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
clindamycin ph 1% gel (generic for cleocin t) 2
clindamycin ph 1% solution 2 QL 60 ML / 30 DAYS
clindamycin phosphate (phos 1% pledget, phosp 1%lotion, 2% vaginal cream)
2
clindamycin-benzoyl peroxide 2
erythromycin 2% gel 2
erythromycin 2% solution 1 QL 60 ML / 30 DAYS
erythromycin-benzoyl peroxide 2
gentamicin 0.1% cream 2 QL 30 GM / 30 DAYS
gentamicin 0.1% ointment 1
metronidazole (cream, lotion, topical gl) 2
metronidazole vaginal 0.75% gl 1
mupirocin 2% cream 2QL 30 GM / 30 DAYS
PA
mupirocin 2% ointment 1 QL 44 GM / RX
ROSADAN 0.75% CREAM 2
LOCAL ANTI-INFECTIVES, MISCELLANEOUSdermazene cream 2
hydrocortisone-iodoquinol 2
selenium sulfide 2.5% lotion 2
silver sulfadiazine 2
sodium sulf-sulfur cleanser 2
SSD 2
sulfacetamide sodium (sod top susp, sodium lotn) 2
SCABICIDES AND PEDICULICIDESmalathion 2
permethrin 2
PAGE 8 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTI-INFLAMMATORY AGENTS (EENT)CORTICOSTEROIDS (EENT)
dexamethasone 0.1% eye drop 2
flunisolide 2
fluocinolone acetonide oil 2
fluorometholone 2
fluticasone prop 50 mcg spray 1
FML S.O.P. 3
loteprednol etabonate 0.5% drp 2
prednisolone ac 1% eye drop (generic pred forte) 2
prednisolone sod 1% eye drop 1
EENT ANTI-INFLAMMATORY AGENTS, MISC.RESTASIS 3
RESTASIS MULTIDOSE 3
EENT NONSTEROIDAL ANTI-INFLAM. AGENTSbromfenac sodium 2
diclofenac 0.1% eye drops 1
flurbiprofen sodium 1
ketorolac tromethamine (0.4% solution, 0.5% solution) 2
ANTI-INFLAMMATORY AGENTS (RESPIRATORY)INTERLEUKIN ANTAGONISTS
DUPIXENT 200 MG/1.14 ML PEN 5
QL 2 PENS / 28 day(s)
PA
S
DUPIXENT 200 MG/1.14 ML SYRING 5
QL 2.28 ML / 28 DAYS
PA
S
FASENRA PEN 5PA
S
PAGE 9 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NUCALA (100 MG/ML AUTO-INJECTOR, 100 MG/MLSYRINGE)
5PA
S
LEUKOTRIENE MODIFIERSmontelukast sod 10 mg tablet 1
montelukast sodium (4 mg granules, 4 mg tab chew, 5 mgtab chew)
2
MAST-CELL STABILIZERS
cromolyn 20 mg/2 ml neb soln 2 PA
cromolyn 4% eye drops 2
ANTI-INFLAMMATORY AGENTS (SKIN, MUCOUS)ANTI-INFLAMMATORY AGENTS, MISC (SKIN)
EUCRISA 3QL 60 GM / 30 DAYS
ST
CORTICOSTEROIDS (SKIN, MUCOUS MEMBRANE)alclometasone dipropionate 2
anucort-hc 2
betamethasone diprop augmented (gel, lot, oin) 2
betamethasone dipropionate (crm, lot, oint) 2
betamethasone dp aug 0.05% crm 1
betamethasone valerate (va cream, va lotion, valer ointm) 2
clobetasol emollient 0.05% crm 2
clobetasol propionate (cream, gel, ointment, solution) 2
desonide (cream, lotion, ointment) 2
desoximetasone (0.05% cream, 0.05% gel, 0.25% cream,0.25% ointment)
2
fluocinolone 0.01% solution 2 QL 60 ML / 30 DAYS
fluocinolone acetonide (0.01% body oil, 0.01% cream,0.01% scalp oil, 0.025% cream, 0.025% ointment)
2
fluocinonide (0.05% cream, 0.05% gel, 0.05% ointment,0.05% solution, 0.1% cream)
2
PAGE 10 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
fluocinonide-e 2
fluticasone propionate (0.005% oint, 0.05% cream) 2
hydrocortisone (2.5% cream, 2.5% lotion, 100 mg/60 ml) 2
hydrocortisone 2.5% ointment 1
hydrocortisone ac 25 mg supp 2
hydrocortisone butyrate (buty cream, butyr oint) 2
hydrocortisone valerate 2
hydrocortisone-pramoxine (1%-1% crm, 2.5-1% crm) 2
mometasone furoate (cream, oint, soln) 2
PROCTO-MED HC 2
PROCTOSOL-HC 2
PROCTOZONE-HC 2
triamcinolone 0.1% paste 1
triamcinolone acetonide (0.025% cream, 0.025% lotion,0.025% oint, 0.1% cream, 0.1% lotion, 0.1% ointment,0.5% cream, 0.5% ointment)
2
TRIDERM 2
ANTIARRHYTHMIC AGENTSCLASS IA ANTIARRHYTHMICS
disopyramide phosphate 2
NORPACE CR 3
quinidine sulfate 2
CLASS IB ANTIARRHYTHMICSmexiletine hcl 2
CLASS IC ANTIARRHYTHMICSflecainide acetate 2
propafenone hcl 2
CLASS III ANTIARRHYTHMICSamiodarone hcl (100 mg tablet, 200 mg tablet, 400 mgtablet)
2
PAGE 11 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
dofetilide 2
MULTAQ 3 PA
PACERONE (100 MG TABLET, 400 MG TABLET) 2
ANTIBACTERIALSAMINOGLYCOSIDE ANTIBIOTICS
neomycin sulfate 2
tobramycin 300 mg/5 ml ampule 5PA
S
QUINOLONE ANTIBIOTICS
CIPRO (5% SUSPENSION, 10% SUSPENSION) 3 AL1 Up to 12 yrs old
ciprofloxacin 2 AL1 Up to 12 yrs old
ciprofloxacin hcl (100 mg tab, 250 mg tab, 500 mg tab,750 mg tab)
1
levofloxacin (250 mg tablet, 500 mg tablet, 750 mgtablet)
1
levofloxacin 25 mg/ml solution 2 AL1 Up to 12 yrs old
moxifloxacin hcl 2
SULFONAMIDE ANTIBIOTICS (SYSTEMIC)sulfamethoxazole-tmp susp 2
sulfamethoxazole-trimethoprim (ds tablet, ss tablet) 1
sulfasalazine 2
sulfasalazine dr 2
SULFATRIM 2
TETRACYCLINE ANTIBIOTICSdemeclocycline hcl 2
doxycycline 25 mg/5 ml susp 2 AL1 Up to 12 yrs old
doxycycline hyclate (50 mg cap, 100 mg cap, 100 mg tab) 1
doxycycline monohydrate (50 mg cap, 50 mg tablet, 100mg cap, 100 mg tablet)
2
PAGE 12 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSminocycline hcl (50 mg capsule, 75 mg capsule, 100 mgcapsule)
2
MONDOXYNE NL 100 MG CAPSULE 2
ANTIBACTERIALS, MISCELLANEOUSGLYCOPEPTIDE ANTIBIOTICS
vancomycin hcl 125 mg capsule 2
vancomycin hcl 250 mg capsule 1
LINCOMYCIN ANTIBIOTICS
clindamycin (pediatric) 2 AL1 Up to 12 yrs old
clindamycin hcl (150 mg capsule, 300 mg capsule) 1
clindamycin hcl 75 mg capsule 2
OXAZOLIDINONE ANTIBIOTICS
linezolid 100 mg/5 ml susp 2 PA
linezolid 600 mg tablet 2 QL 28 TABS / RX
SIVEXTRO 200 MG TABLET 3 PA
PLEUROMUTILINS
XENLETA 600 MG TABLET 3QL 10 TABS / RX
PA
RIFAMYCIN ANTIBIOTICS
XIFAXAN 3 PA
ANTICHOLINERGIC AGENTSANTIMUSCARINICS/ANTISPASMODICS
ANORO ELLIPTA 3
ATROVENT HFA 3 QL 1 INHALER / 25 DAYS
COMBIVENT RESPIMAT 3 QL 1 INHALER / 30 DAYS
CUVPOSA 3 PA
dicyclomine 10 mg capsule 2
dicyclomine hcl (10 mg/5 ml soln, 20 mg tablet) 1
PAGE 13 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ed-spaz 2
glycopyrrolate (1 mg tablet, 2 mg tablet) 2
hyoscyamine sulfate (0.125 mg odt, 0.125 mg tab sl,0.125 mg/5 ml elix, 0.125 mg/ml drop, sulf 0.125 mg tab)
2
hyoscyamine sulfate er 2
hyoscyamine sulfate sr 2
hyosyne 2
INCRUSE ELLIPTA 3
ipratropium br 0.02% soln 2
ipratropium-albuterol 2
oscimin 2
oscimin sl 2
oscimin sr 2
propantheline bromide 2
symax-sr 2
ANTICOAGULANTSANTICOAGULANTS, MISCELLANEOUS
fondaparinux sodium 2QL 1 SYRINGE / 1 DAY
PA
COUMARIN DERIVATIVESjantoven 1
warfarin sodium 1
DIRECT FACTOR XA INHIBITORS
ELIQUIS (2.5 MG TABLET, 5 MG TABLET) 3 QL 2 TABS / 1 DAY
ELIQUIS DVT-PE TREAT START 5MG 3 QL 1 RX / 30 DAYS
XARELTO (10 MG TABLET, 20 MG TABLET) 3 QL 1 TAB / 1 DAY
XARELTO (2.5 MG TABLET, 15 MG TABLET) 3 QL 2 TABS / 1 DAY
XARELTO DVT-PE TREAT START 30D 3 QL 51 TABS / 30 DAYS
PAGE 14 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIRECT THROMBIN INHIBITORS
PRADAXA 3 PA
HEPARINS
enoxaparin 300 mg/3 ml vial 2 QL 2 VIALS / 1 DAY
enoxaparin sodium (30 mg/0.3 ml syr, 40 mg/0.4 ml syr,60 mg/0.6 ml syr, 80 mg/0.8 ml syr, 100 mg/ml syringe,120 mg/0.8 ml syr, 150 mg/ml syringe)
2 QL 2 SYRINGES / 1 DAY
heparin sodium (sod 1,000 unit/ml vial, 5,000 unit/mlcarpujct, sod 5,000 unit/0.5 ml, sod 5,000 unit/ml syrg,sod 5,000 unit/ml vial, 10,000 unit/10 ml vial, sod 10,000unit/ml vl, sod 20,000 unit/ml vl, 30,000 unit/30 ml vial,40,000 unit/4 ml vial, 50,000 unit/10 ml vial, 50,000unit/5 ml vial)
2
ANTICONVULSANTSANTICONVULSANTS, MISCELLANEOUS
APTIOM 3 PA
BANZEL 200 MG TABLET 3QL 16 TABS / 1 DAY
PA
BANZEL 400 MG TABLET 3QL 8 TABS / 1 DAY
PA
BRIVIACT (10 MG TABLET, 10 MG/ML ORAL SOLN, 25 MGTABLET, 50 MG TABLET, 75 MG TABLET, 100 MG TABLET)
3 PA
carbamazepine (100 mg tab chew, 100 mg/5 ml susp, 200mg tablet)
2
carbamazepine er 2
DIACOMIT 250 MG CAPSULE 5
QL 12 CAPS / 1 DAY
PA
S
DIACOMIT 250 MG POWDER PACKET 5
QL 12 PACKETS / 1 DAY
PA
S
DIACOMIT 500 MG CAPSULE 5
QL 6 CAPS / 1 DAY
PA
S
PAGE 15 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIACOMIT 500 MG POWDER PACKET 5
QL 6 PACKETS / 1 DAY
PA
S
divalproex sodium (dr 125 mg cap sprnk, dr 125 mgcp(sprnk))
1
divalproex sodium (dr 125 mg tab, dr 250 mg tab, dr 500mg tab)
2
divalproex sodium er 1
EPIDIOLEX 5
QL 20 ML / 1 DAY
PA
S
felbamate (400 mg tablet, 600 mg tablet, 600 mg/5 mlsusp)
2
FINTEPLA 5PA
S
FYCOMPA (0.5 MG/ML ORAL SUSP, 2 MG TABLET, 4 MGTABLET, 6 MG TABLET, 8 MG TABLET, 10 MG TABLET, 12MG TABLET)
3 PA
gabapentin (100 mg capsule, 300 mg capsule) 2 QL 12 CAPS / 1 DAY
gabapentin (250 mg/5 ml soln, 300 mg/6 ml soln) 2 QL 72 ML / 1 DAY
gabapentin 400 mg capsule 2 QL 9 CAPS / 1 DAY
gabapentin 600 mg tablet 2 QL 6 TABS / 1 DAY
gabapentin 800 mg tablet 2 QL 4 TABS / 1 DAY
lamotrigine 2
levetiracetam (100 mg/ml soln, 250 mg tablet, 500 mgtablet, 750 mg tablet, 1,000 mg tablet, 1000 mg/10 ml)
2
levetiracetam er 1
oxcarbazepine (150 mg tablet, 300 mg tablet, 300 mg/5ml susp, 600 mg tablet)
2
pregabalin (225 mg capsule, 300 mg capsule) 2 QL 2 CAPS / 1 DAY
PAGE 16 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSpregabalin (25 mg capsule, 50 mg capsule, 75 mg capsule,100 mg capsule, 150 mg capsule, 200 mg capsule)
2 QL 3 CAPS / 1 DAY
pregabalin 20 mg/ml solution 2 QL 30 ML / 1 DAY
rufinamide 200 mg tablet 2QL 16 TABS / 1 DAY
PA
rufinamide 40 mg/ml suspension 2QL 80 ML / 1 DAY
PA
rufinamide 400 mg tablet 2QL 8 TABS / 1 DAY
PA
SUBVENITE 2
tiagabine hcl 2
topiramate 1
valproic acid (250 mg capsule, 250 mg/5 ml soln, 500mg/10 ml sol)
2
vigabatrin 5PA
S
VIGADRONE 5PA
S
VIMPAT (150 MG TABLET, 200 MG TABLET) 3 QL 2 TABS / 1 DAY
VIMPAT 10 MG/ML SOLUTION 3 QL 40 ML / 1 DAY
VIMPAT 100 MG TABLET 3 QL 4 TABS / 1 DAY
VIMPAT 50 MG TABLET 3 QL 8 TABS / 1 DAY
zonisamide 1
BARBITURATES (ANTICONVULSANTS)primidone 2
BENZODIAZEPINES (ANTICONVULSANTS)
clobazam 10 mg tablet 2 QL 4 TABS / 1 DAY
clobazam 2.5 mg/ml suspension 2 QL 16 ML / 1 DAY
PAGE 17 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
clobazam 20 mg tablet 2 QL 2 TABS / 1 DAY
clonazepam (0.125 mg dis tab, 0.125 mg odt, 0.25 mgodt, 0.5 mg dis tablet, 0.5 mg odt, 0.5 mg tablet)
1 QL 6 TABS / 1 DAY
clonazepam (1 mg dis tablet, 1 mg odt, 1 mg tablet) 1 QL 4 TABS / 1 DAY
clonazepam (2 mg odt, 2 mg tablet) 1 QL 2 TABS / 1 DAY
NAYZILAM 3QL 2 BOTTLES / RX
PA
HYDANTOINSDILANTIN 30 MG CAPSULE 3
phenytoin (50 mg infatab, 50 mg tablet chew, 100 mg/4ml susp, 125 mg/5 ml susp)
2
phenytoin sodium extended 2
SUCCINIMIDESethosuximide (250 mg capsule, 250 mg/5 ml soln) 2
ANTIDEPRESSANTSANTIDEPRESSANTS, MISCELLANEOUS
bupropion hcl 2
bupropion hcl sr 2
bupropion xl (150 mg tablet, 300 mg tablet) 2
mirtazapine (7.5 mg tablet, 15 mg tablet, 30 mg tablet, 45mg tablet)
2
MONOAMINE OXIDASE INHIBITORSphenelzine sulfate 2
tranylcypromine sulfate 2
SEL.SEROTONIN,NOREPI REUPTAKE INHIBITORdesvenlafaxine suc er 100 mg tablet (generic for pristiq) 1
desvenlafaxine suc er 25 mg tablet (generic for pristiq) 1
desvenlafaxine suc er 50 mg tablet (generic for pristiq) 1
duloxetine hcl (dr 20 mg cap, dr 30 mg cap, dr 60 mg cap) 2
FETZIMA 3 PA
PAGE 18 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
venlafaxine hcl 2
venlafaxine hcl er (er 37.5 mg cap, er 75 mg cap, er 150mg cap)
2
SELECTIVE-SEROTONIN REUPTAKE INHIBITORScitalopram hbr (10 mg tablet, 20 mg tablet, 40 mg tablet) 1
citalopram hbr (10 mg/5 ml soln, 20 mg/10 ml sol) 2
escitalopram oxalate (5 mg tablet, 10 mg tablet, 20 mgtablet)
1
escitalopram oxalate 5 mg/5 ml 2
fluoxetine 20 mg/5 ml solution 2
fluoxetine hcl (10 mg capsule, 20 mg capsule, 40 mgcapsule)
1
fluvoxamine maleate 2
paroxetine hcl 1
PAXIL 10 MG/5 ML SUSPENSION 3
sertraline hcl (20 mg/ml oral conc, hcl 25 mg tablet, hcl 50mg tablet, hcl 100 mg tablet)
1
SEROTONIN MODULATORSnefazodone hcl 2
trazodone hcl 1
TRINTELLIX 3 PA
VIIBRYD 3 PA
TRICYCLICS, OTHER NOREPI-RU INHIBITORSamitriptyline hcl 2
clomipramine hcl 2
desipramine hcl 2
doxepin hcl (10 mg capsule, 10 mg/ml oral conc, 25 mgcapsule, 50 mg capsule, 75 mg capsule, 100 mg capsule,150 mg capsule)
2
imipramine hcl 2
nortriptyline hcl (10 mg/5 ml soln, hcl 10 mg cap, hcl 25mg cap, hcl 50 mg cap, hcl 75 mg cap)
2
PAGE 19 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIDIABETIC AGENTSALPHA-GLUCOSIDASE INHIBITORS
acarbose 1
miglitol 2
BIGUANIDESmetformin hcl 1,000 mg tablet (generic for glucophage) 1
metformin hcl 500 mg tablet (generic for glucophage) 1
metformin hcl 850 mg tablet 1
metformin hcl er 1
DIPEPTIDYL PEPTIDASE-4(DPP-4) INHIBITORS
alogliptin 2 QL 1 TAB / 1 DAY
alogliptin-metformin 2 QL 2 TABS / 1 DAY
alogliptin-pioglitazone 2 QL 1 TAB / 1 DAY
JENTADUETO 3 QL 2 TABS / 1 DAY
JENTADUETO XR 3 QL 2 TABS / 1 DAY
TRADJENTA 3 QL 1 TAB / 1 DAY
INCRETIN MIMETICS
BYDUREON BCISE 3 QL 3.4 ML / 28 DAYS
BYDUREON PEN 3 QL 4 PEN / 28 DAYS
BYETTA 10 MCG DOSE PEN INJ 3 QL 2.4 ML / 30 DAYS
BYETTA 5 MCG DOSE PEN INJ 3 QL 1.2 ML / 30 DAYS
OZEMPIC (1 MG/DOSE (2 MG/1.5ML), 1 MG/DOSE (4MG/3 ML))
3 QL 3 ML / 28 DAYS
OZEMPIC 0.25-0.5 MG/DOSE PEN 3 QL 1.5 ML / 28 DAYS
RYBELSUS 3 QL 1 TAB / 1 DAY
TRULICITY 3 QL 2 ML / 28 DAYS
VICTOZA 2-PAK 3 QL 9 ML / 30 DAYS
PAGE 20 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VICTOZA 3-PAK 3 QL 9 ML / 30 DAYS
MEGLITINIDESnateglinide 2
repaglinide 2
SODIUM-GLUC COTRANSPORT 2 (SGLT2) INHIB
GLYXAMBI 3 QL 1 TAB / 1 DAY
INVOKAMET 3 QL 2 TABS / 1 DAY
INVOKAMET XR 3 QL 2 TABS / 1 DAY
INVOKANA 3 QL 1 TAB / 1 DAY
JARDIANCE 3 QL 1 TAB / 1 DAY
SYNJARDY 3 QL 2 TABS / 1 DAY
SYNJARDY XR (10-1,000 MG TABLET, 25-1,000 MGTABLET)
3 QL 1 TAB / 1 DAY
SYNJARDY XR (5-1,000 MG TABLET, 12.5-1,000 MG TAB) 3 QL 2 TABS / 1 DAY
TRIJARDY XR (10-5-1,000 MG TAB, 25-5-1,000 MG TAB) 3 QL 1 TAB / 1 DAY
TRIJARDY XR (5-2.5-1,000 MG TAB, 12.5-2.5-1,000 MG) 3 QL 2 TABS / 1 DAY
SULFONYLUREASglimepiride 1
glipizide 1
glipizide er 1
glipizide xl 1
glipizide-metformin 1
glyburide 2 PA
glyburide micronized 2 PA
glyburide-metformin hcl 2 PA
PAGE 21 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
THIAZOLIDINEDIONESpioglitazone hcl 1
pioglitazone-glimepiride 2
pioglitazone-metformin 2
ANTIEMETICS5-HT3 RECEPTOR ANTAGONISTS
ondansetron 4 mg/5 ml solution 1
ondansetron hcl (4 mg tablet, 8 mg tablet, 24 mg tablet) 2
ondansetron odt 2
ANTIEMETICS, MISCELLANEOUS
dronabinol (2.5 mg capsule, 5 mg capsule) 2 QL 6 CAPS / 1 DAY
dronabinol 10 mg capsule 1 QL 4 CAPS / 1 DAY
scopolamine 2
ANTIHISTAMINES (GI DRUGS)prochlorperazine 2
prochlorperazine maleate 1
trimethobenzamide hcl 2
NEUROKININ-1 RECEPTOR ANTAGONISTSaprepitant 2
EMEND 125 MG POWDER PACKET 3
ANTIFUNGAL (SYSTEMIC)ALLYLAMINE ANTIFUNGALS
terbinafine hcl 1
ANTIFUNGALS, MISCELLANEOUSgriseofulvin (125 mg/5 ml susp, micro 500 mg tab) 2
griseofulvin ultramicrosize 2
AZOLE ANTIFUNGALS
CRESEMBA 186 MG CAPSULE 3 PA
fluconazole (10 mg/ml susp, 40 mg/ml susp) 2
PAGE 22 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSfluconazole (50 mg tablet, 100 mg tablet, 150 mg tablet,200 mg tablet)
1
itraconazole 100 mg capsule 2
ketoconazole 200 mg tablet 1
posaconazole 2 PA
voriconazole (40 mg/ml susp, 50 mg tablet, 200 mgtablet)
2 PA
POLYENE ANTIFUNGALS
nystatin (100,000 unit/ml susp, 500,000 unit/5 ml sus) 2 QL 480 ML / RX
nystatin 500,000 unit oral tab 1
ANTIFUNGALS (SKIN AND MUCOUS MEMBRANE)AZOLES (SKIN AND MUCOUS MEMBRANE)
clotrimazole 10 mg troche 2
clotrimazole-betamethasone crm 2
econazole nitrate 2 QL 85 GM / 30 DAYS
ketoconazole 2% cream 1 QL 60 GM / 30 DAYS
ketoconazole 2% shampoo 2
terconazole (0.4% cream, 0.8% cream, 80 mg suppository) 2
HYDROXYPYRIDONES (SKIN, MUCOUS MEMBRANE)ciclopirox (0.77% cream, 0.77% gel, 1% shampoo, 8%solution)
2
ciclopirox 0.77% topical susp 2 QL 60 ML / 30 DAYS
POLYENES (SKIN AND MUCOUS MEMBRANE)nystatin (unit/gm cream, unit/gm oint) 2
nystatin 100,000 unit/gm powd 2 QL 240 GM / RX
ANTIGLAUCOMA AGENTSALPHA-ADRENERGIC AGONISTS (EENT)
brimonidine tartrate 2
PAGE 23 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BETA-ADRENERGIC BLOCKING AGENTS (EENT)betaxolol hcl 0.5% eye drop 2
carteolol hcl 1
levobunolol hcl 1
timolol maleate (0.25%, 0.25% gfs, 0.5%, 0.5% gfs) 2
timolol maleate 0.25% eye drop (generic for timoptic) 1
timolol maleate 0.5% eye drops (generic for timoptic) 1
CARBONIC ANHYDRASE INHIBITORS (EENT)acetazolamide 1
acetazolamide er 2
dorzolamide hcl 2
dorzolamide-timolol (2%-0.5%, eye drops) 2
methazolamide 2
MIOTICSpilocarpine hcl (1% drops, 2% drops, 4% drops) 2
PROSTAGLANDIN ANALOGSbimatoprost 0.03% eye drops 2
latanoprost 2
LUMIGAN 3
travoprost 2
ZIOPTAN 3 PA
RHO KINASE INHIBITORSRHOPRESSA 3
ROCKLATAN 3
ANTIHEMORRHAGIC AGENTSHEMOSTATICS
ADVATE 5PA
S
ADYNOVATE 5PA
S
PAGE 24 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AFSTYLA 5PA
S
ALPHANATE 5PA
S
ALPHANINE SD 5PA
S
ALPROLIX 5PA
S
BENEFIX 5PA
S
COAGADEX 5PA
S
CORIFACT 5PA
S
ELOCTATE 5PA
S
ESPEROCT 5PA
S
FEIBA NF 5PA
S
HELIXATE FS 5PA
S
HEMLIBRA 5PA
S
HEMOFIL M 5PA
S
HUMATE-P 5PA
S
PAGE 25 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
IDELVION 5PA
S
IXINITY 5PA
S
JIVI 5PA
S
KOATE 5PA
S
KOGENATE FS 5PA
S
KOVALTRY 5PA
S
MONONINE 5 S
NOVOEIGHT 5PA
S
NOVOSEVEN RT 5PA
S
NUWIQ 5PA
S
OBIZUR 5PA
S
PROFILNINE 5PA
S
REBINYN 5PA
S
RECOMBINATE 5PA
S
RIXUBIS 5PA
S
PAGE 26 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SEVENFACT 5PA
S
tranexamic acid 650 mg tablet 2 QL 30 TABS / RX
TRETTEN 5PA
S
VONVENDI 5PA
S
WILATE 5PA
S
XYNTHA 5PA
S
XYNTHA SOLOFUSE 5PA
S
ANTIHYPOGLYCEMIC AGENTSGLYCOGENOLYTIC AGENTS
BAQSIMI 3
glucagon 1 mg emergency kit 2
glucagon 1 mg emergency kit (generic glucagen) 2
GLUCAGON 1 MG EMERGENCY KIT (LILLY) 3
GLUCAGON 1 MG VIAL 3
GVOKE HYPOPEN 1-PACK 3
GVOKE HYPOPEN 2-PACK 3
GVOKE PFS 1-PACK SYRINGE 3
GVOKE PFS 2-PACK SYRINGE 3
ZEGALOGUE AUTOINJECTOR 3
ZEGALOGUE SYRINGE 3
PAGE 27 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTILIPEMIC AGENTSANTILIPEMIC AGENTS, MISCELLANEOUS
icosapent ethyl 2 PA
JUXTAPID 5PA
S
omega-3 acid ethyl esters 1
TRIKLO 1
VASCEPA 3 PA
BILE ACID SEQUESTRANTScholestyramine (packet, powder) 2
cholestyramine light (packet, powder) 2
colestipol hcl 1 gm tablet 2
PREVALITE (PACKET, POWDER) 2
CHOLESTEROL ABSORPTION INHIBITORSezetimibe 1
FIBRIC ACID DERIVATIVESfenofibrate (48 mg tablet, 67 mg capsule, 134 mg capsule,145 mg tablet, 200 mg capsule)
1
fenofibrate (54 mg tablet, 160 mg tablet) 2
gemfibrozil 1
HMG-COA REDUCTASE INHIBITORS
atorvastatin calcium (10 mg tablet, 20 mg tablet) 1 ACA Affordable Care Act
atorvastatin calcium (40 mg tablet, 80 mg tablet) 1
lovastatin (20 mg tablet, 40 mg tablet) 1 ACA Affordable Care Act
lovastatin 10 mg tablet 1
pravastatin sodium 1 ACA Affordable Care Act
rosuvastatin calcium (20 mg tab, 40 mg tab) 1
rosuvastatin calcium (5 mg tab, 10 mg tab) 1 ACA Affordable Care Act
PAGE 28 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
simvastatin (10 mg tablet, 20 mg tablet, 40 mg tablet) 1 ACA Affordable Care Act
simvastatin (5 mg tablet, 80 mg tablet) 1
PCSK9 INHIBITORS
REPATHA PUSHTRONEX 3QL 1 PEN / 28 DAYS
PA
REPATHA SURECLICK 3QL 2 PENS / 28 DAYS
PA
REPATHA SYRINGE 3QL 2 PENS / 28 DAYS
PA
ANTIMIGRAINE AGENTSCALCITONIN GENE-RELATED PEPTIDE ANTAG.
AJOVY AUTOINJECTOR 5
QL 1.5 ML / 30 DAYS
PA
S
AJOVY SYRINGE 5
QL 1.5 ML / 30 DAYS
PA
S
EMGALITY 120 MG/ML SYRINGE 5
QL 1 ML / 30 DAYS
PA
S
EMGALITY PEN 5
QL 1 ML / 30 DAYS
PA
S
EMGALITY SYRINGE (100 MG/ML SYR(1 OF 3), 300 MG(100 MG X3SYR))
5
QL 3 ML / 30 DAYS
PA
S
NURTEC ODT 3QL 8 TABS / 30 DAYS
PA
PAGE 29 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SELECTIVE SEROTONIN AGONISTS
eletriptan hbr 2QL 12 TABS / 28 DAYS
PA
naratriptan hcl 1 QL 12 TABS / 30 DAYS
REYVOW 3QL 8 TABS / 30 DAYS
PA
rizatriptan 2 QL 12 TABS / 28 DAYS
sumatriptan 2 QL 12 ML / 30 DAYS
sumatriptan succinate (25 mg tablet, 50 mg tablet, 100mg tablet)
2 QL 12 TABS / 28 DAYS
sumatriptan succinate (4 mg/0.5 ml cart, 4 mg/0.5 mlinject, 6 mg/0.5 ml cart, 6 mg/0.5 ml inject, 6 mg/0.5 mlsyrng, 6 mg/0.5 ml vial)
2 QL 5 ML / 30 DAYS
zolmitriptan (2.5 mg tablet, 5 mg tablet) 2 QL 12 TABS / 28 DAYS
zolmitriptan odt 2 QL 12 TABS / 28 DAYS
ANTIMYCOBACTERIALSANTIMYCOBACTERIALS, MISCELLANEOUS
dapsone (25 mg tablet, 100 mg tablet) 2
ANTITUBERCULOSIS AGENTS
cycloserine 2 PA
ethambutol hcl 1
isoniazid (100 mg tablet, 300 mg tablet) 1
isoniazid 50 mg/5 ml solution 2
pretomanid 2 PA
PRIFTIN 3
pyrazinamide 2
rifabutin 2
rifampin (150 mg capsule, 300 mg capsule) 1
SIRTURO 3 PA
PAGE 30 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRECATOR 3 PA
ANTINEOPLASTIC AGENTS
abiraterone 500 mg tablet 2
QL 2 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
abiraterone acetate 250 mg tab 2
QL 4 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
AFINITOR 10 MG TABLET 3
QL 1 TAB / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
AFINITOR DISPERZ (2 MG TABLET, 5 MG TABLET) 3
QL 2 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
AFINITOR DISPERZ 3 MG TABLET 3
QL 3 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
ALECENSA 3
QL 8 CAPS / 30 DAYS
PA
S
ONC Oncology
PAGE 31 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
anastrozole 1 ACA Affordable Care Act
AYVAKIT 3
QL 1 TAB / 1 DAY
PA
S
ONC Oncology
BALVERSA 3PA
S
bicalutamide 1
BOSULIF (400 MG TABLET, 500 MG TABLET) 3
QL 1 TAB / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
BOSULIF 100 MG TABLET 3
QL 4 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
BRAFTOVI 50 MG CAPSULE 3
QL 2 CAPS / 1 DAY
PA
S
BRAFTOVI 75 MG CAPSULE 3
QL 6 CAPS / 1 DAY
PA
S
BRUKINSA 5
PA
S
ONC Oncology
CABOMETYX 3
QL 1 TAB / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
PAGE 32 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
capecitabine 2S
ONC Oncology
CAPRELSA 100 MG TABLET 3
QL 2 TABS / 1 DAY
PA
S
ONC Oncology
CAPRELSA 300 MG TABLET 3
QL 1 TAB / 1 DAY
PA
S
ONC Oncology
COMETRIQ 100 MG DAILY-DOSE PK 3
QL 2 CAPS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
COMETRIQ 140 MG DAILY-DOSE PK 3
QL 4 CAPS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
COMETRIQ 60 MG DAILY-DOSE PACK 3
QL 3 CAPS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
COPIKTRA 3
QL 2 CAPS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
COTELLIC 3
QL 3 TABS / 1 DAY
PA
S
ONC Oncology
PAGE 33 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSCYCLOPHOSPHAMIDE (25 MG CAPSULE, 25 MG TABLET,50 MG CAPSULE, 50 MG TABLET)
2
DAURISMO 100 MG TABLET 3
QL 1 TAB / 1 DAY
PA
S
TD Trial Drug
DAURISMO 25 MG TABLET 3
QL 3 TABS / 1 DAY
PA
S
TD Trial Drug
EMCYT 3
ERIVEDGE 3
QL 1 CAP / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
ERLEADA 3
PA
S
ONC Oncology
erlotinib hcl (100 mg tablet, 150 mg tablet) 2
QL 1 TAB / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
erlotinib hcl 25 mg tablet 2
QL 3 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
etoposide 50 mg capsule 2
PAGE 34 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
exemestane 2 ACA Affordable Care Act
fluorouracil (2% topical soln, 5% cream, 5% topical soln) 2
flutamide 2
FOTIVDA 3
QL 21 CAPS / 28 DAYS
PA
S
ONC Oncology
GAVRETO 3
PA
S
ONC Oncology
GILOTRIF 3
QL 1 TAB / 1 DAY
PA
S
ONC Oncology
GLEOSTINE 3
HYCAMTIN 3S
ONC Oncology
hydroxyurea 2
IBRANCE (75 MG CAPSULE, 100 MG CAPSULE, 125 MGCAPSULE)
3
QL 21 CAPS / 28 DAYS
PA
S
ONC Oncology
IBRANCE (75 MG TABLET, 100 MG TABLET, 125 MGTABLET)
3
QL 21 TABS / 28 DAYS
PA
S
ONC Oncology
ICLUSIG (10 MG TABLET, 15 MG TABLET) 3
QL 2 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
PAGE 35 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ICLUSIG (30 MG TABLET, 45 MG TABLET) 3
QL 1 TAB / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
IDHIFA 3
QL 1 TAB / 1 DAY
PA
S
ONC Oncology
imatinib mesylate 2
S
TD Trial Drug
ONC Oncology
IMBRUVICA (420 MG TABLET, 560 MG TABLET) 3
QL 1 TAB / 1 DAY
PA
S
ONC Oncology
IMBRUVICA 140 MG CAPSULE 3
QL 4 CAPS / 1 DAY
PA
S
ONC Oncology
IMBRUVICA 70 MG CAPSULE 3
QL 1 CAP / 1 DAY
PA
S
ONC Oncology
INLYTA 1 MG TABLET 3
QL 6 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
INLYTA 5 MG TABLET 3
QL 4 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
PAGE 36 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INQOVI 3
QL 5 TABS / 28 DAYS
PA
S
ONC Oncology
INREBIC 3
PA
S
ONC Oncology
IRESSA 3
QL 1 TAB / 1 DAY
PA
S
ONC Oncology
JAKAFI 3
QL 2 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
KISQALI 200 MG DAILY DOSE 3
QL 21 TABS / 28 DAYS
PA
S
ONC Oncology
KISQALI 400 MG DAILY DOSE 3
QL 42 TABS / 28 DAYS
PA
S
ONC Oncology
KISQALI 600 MG DAILY DOSE 3
QL 63 TABS / 28 DAYS
PA
S
ONC Oncology
KISQALI FEMARA 200 MG CO-PACK 3
QL 49 TABS / 28 DAYS
PA
S
ONC Oncology
PAGE 37 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
KISQALI FEMARA 400 MG CO-PACK 3
QL 70 TABS / 28 DAYS
PA
S
ONC Oncology
KISQALI FEMARA 600 MG CO-PACK 3
QL 91 TABS / 28 DAYS
PA
S
ONC Oncology
KOSELUGO 10 MG CAPSULE 3
QL 8 CAPS / 1 DAY
PA
S
ONC Oncology
KOSELUGO 25 MG CAPSULE 3
QL 4 CAPS / 1 DAY
PA
S
ONC Oncology
lapatinib 2
QL 6 TABS / 1 DAY
PA
S
ONC Oncology
letrozole 2 ACA Affordable Care Act
LEUKERAN 3
LONSURF 15 MG-6.14 MG TABLET 3
QL 2 TABS / 1 DAY
PA
S
ONC Oncology
LONSURF 20 MG-8.19 MG TABLET 3
QL 3 TABS / 1 DAY
PA
S
ONC Oncology
LORBRENA 100 MG TABLET 3
QL 1 TAB / 1 DAY
PA
S
TD Trial DrugPAGE 38 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LORBRENA 25 MG TABLET 3
QL 3 TABS / 1 DAY
PA
S
TD Trial Drug
LUMAKRAS 3
PA
S
ONC Oncology
LYNPARZA 3
QL 4 TABS / 1 DAY
PA
S
TD Trial Drug
LYSODREN 3PA
S
MATULANE 3
QL 2 CAPS / 1 DAY
PA
S
ONC Oncology
MEKINIST 0.5 MG TABLET 3
QL 3 TABS / 1 DAY
PA
S
ONC Oncology
MEKINIST 2 MG TABLET 3
QL 1 TAB / 1 DAY
PA
S
ONC Oncology
MEKTOVI 3
QL 6 TABS / 1 DAY
PA
S
melphalan 2
mercaptopurine 2
PAGE 39 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSmethotrexate (2.5 mg tablet, 50 mg/2 ml vial, 250 mg/10ml vial)
2
methotrexate sodium 2
MYLERAN 3
NERLYNX 3
QL 6 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
NEXAVAR 3
QL 4 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
NINLARO 3
QL 3 CAPS / 28 DAYS
PA
S
ONC Oncology
NUBEQA 3PA
S
ODOMZO 3
QL 1 CAP / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
ONUREG 3
QL 14 TABS / 28 DAYS
PA
S
ONC Oncology
PEMAZYRE 3
QL 14 TABS / 21 DAYS
PA
S
ONC Oncology
PAGE 40 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PICATO 3 PA
POMALYST 3
QL 1 CAP / 1 DAY
PA
S
ONC Oncology
QINLOCK 3
QL 3 TABS / 1 DAY
PA
S
ONC Oncology
RASUVO 3 PA
RETEVMO 40 MG CAPSULE 3
QL 6 CAPS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
RETEVMO 80 MG CAPSULE 3
QL 4 CAPS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
REVLIMID 3
QL 1 CAP / 1 DAY
S
ONC Oncology
ROZLYTREK 3
PA
S
ONC Oncology
RYDAPT 3
PA
S
ONC Oncology
SPRYCEL 3
PA
S
TD Trial Drug
ONC Oncology
PAGE 41 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
STIVARGA 3
PA
S
ONC Oncology
sunitinib malate 2
QL 1 CAP / 1 DAY
PA
S
ONC Oncology
TABLOID 3
TABRECTA 3
QL 4 TABS / 1 DAY
PA
S
ONC Oncology
TAFINLAR 3
QL 4 CAPS / 1 DAY
PA
S
ONC Oncology
TAGRISSO 3
QL 1 TAB / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
TASIGNA 3
PA
S
TD Trial Drug
ONC Oncology
TAZVERIK 3
QL 8 TABS / 1 DAY
PA
S
ONC Oncology
temozolomide 2S
ONC Oncology
PAGE 42 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TEPMETKO 3
QL 2 TABS / 1 DAY
PA
S
ONC Oncology
TIBSOVO 3
QL 2 TABS / 1 DAY
PA
S
ONC Oncology
tretinoin 10 mg capsule 2S
ONC Oncology
TRUSELTIQ 3
PA
S
ONC Oncology
TURALIO 3PA
S
UKONIQ 3
QL 4 TABS / 1 DAY
PA
S
ONC Oncology
VALCHLOR 3
QL 120 GM / 30 DAYS
PA
S
ONC Oncology
VERZENIO 3
QL 56 TABS / 28 DAYS
PA
S
ONC Oncology
VITRAKVI 100 MG CAPSULE 3
QL 2 CAPS / 1 DAY
PA
S
TD Trial Drug
PAGE 43 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VITRAKVI 20 MG/ML SOLUTION 3
QL 300 ML / 30 DAYS
PA
S
TD Trial Drug
VITRAKVI 25 MG CAPSULE 3
QL 6 CAPS / 1 DAY
PA
S
TD Trial Drug
VIZIMPRO 3
QL 1 TAB / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
VOTRIENT 3
QL 4 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
WELIREG 3
QL 3 TABS / 1 DAY
PA
S
ONC Oncology
XALKORI 3
QL 2 CAPS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
XOSPATA 3
QL 3 TABS / 1 DAY
PA
S
XPOVIO 3
PA
S
ONC Oncology
PAGE 44 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
XTANDI 3
PA
S
TD Trial Drug
ONC Oncology
ZEJULA 3
QL 3 CAPS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
ZELBORAF 3
QL 8 TABS / 30 DAYS
PA
S
ONC Oncology
ZOLINZA 3
QL 4 CAPS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
ZYKADIA 150 MG CAPSULE 3
QL 3 CAPS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
ZYKADIA 150 MG TABLET 3
QL 3 TABS / 1 DAY
PA
S
TD Trial Drug
ONC Oncology
PAGE 45 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANTIPARKINSONIAN AGENTS (CNS)ADAMANTANES (CNS)
amantadine (50 mg/5 ml solution, 100 mg tablet, 100mg/10 ml soln)
2
amantadine 100 mg capsule 1
ANTICHOLINERGIC AGENTS (CNS)benztropine mesylate (0.5 mg tab, 1 mg tablet, 2 mgtablet)
2
trihexyphenidyl 2 mg/5 ml soln 2
trihexyphenidyl hcl (2 mg tablet, 5 mg tablet) 1
CATECHOL-O-METHYLTRANSFERASE(COMT)INHIB.entacapone 2
DOPAMINE PRECURSORScarbidopa-levodopa 2
carbidopa-levodopa er 2
carbidopa-levodopa-entacapone 2
INBRIJA 5PA
S
RYTARY 3 ST
MONOAMINE OXIDASE B INHIBITORS
rasagiline mesylate 2 PA
selegiline hcl 2
ANTIPROTOZOALSANTIMALARIALS
atovaquone-proguanil hcl 2
chloroquine phosphate 2
hydroxychloroquine 200 mg tab 2
mefloquine hcl 1
ANTIPROTOZOALS, MISCELLANEOUS
ALINIA 100 MG/5 ML SUSPENSION 3 PA
PAGE 46 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
atovaquone 2
benznidazole 2 PA
LAMPIT 3 PA
metronidazole (250 mg tablet, 500 mg tablet) 2
nitazoxanide 2 PA
ANTIPSYCHOTIC AGENTSANTIPSYCHOTICS, MISCELLANEOUS
loxapine 2 AL1 At least 13 yrs old
ATYPICAL ANTIPSYCHOTICSaripiprazole (1 mg/ml solution, 2 mg tablet, 5 mg tablet,10 mg tablet, 15 mg tablet, 20 mg tablet, 30 mg tablet)
2 AL1 At least 13 yrs old
aripiprazole odt 2PA
AL1 At least 13 yrs old
asenapine maleate 2 PA
CAPLYTA 3QL 1 CAP / 1 DAY
PA
clozapine 2 AL1 At least 13 yrs old
clozapine odt (odt 12.5 mg tablet, odt 25 mg tablet, odt100 mg tablet, odt 150 mg tablet)
2PA
AL1 At least 13 yrs old
clozapine odt 200 mg tablet 1PA
AL1 At least 13 yrs old
FANAPT 3 PA
LATUDA 3QL 1 TAB / 1 DAY
PA
NUPLAZID 5
PA
S
TD Trial Drug
olanzapine (2.5 mg tablet, 5 mg tablet, 7.5 mg tablet, 10mg tablet, 15 mg tablet, 20 mg tablet)
2 AL1 At least 13 yrs old
PAGE 47 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
olanzapine odt 2PA
AL1 At least 13 yrs old
paliperidone er 1 PA
quetiapine fumarate 2 AL1 At least 13 yrs old
quetiapine fumarate er 2 AL1 At least 13 yrs old
REXULTI 3 PA
risperidone (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet, 2mg tablet, 3 mg tablet, 4 mg tablet)
1 AL1 At least 13 yrs old
risperidone 1 mg/ml solution 2 AL1 At least 13 yrs old
risperidone odt 2PA
AL1 At least 13 yrs old
SECUADO 3 PA
VERSACLOZ 3PA
AL1 At least 13 yrs old
VRAYLAR (1.5 MG CAPSULE, 1.5 MG-3 MG PACK) 3QL 2 CAPS / 1 DAY
PA
VRAYLAR (3 MG CAPSULE, 4.5 MG CAPSULE, 6 MGCAPSULE)
3QL 1 CAP / 1 DAY
PA
ziprasidone hcl 2 AL1 At least 13 yrs old
BUTYROPHENONES
haloperidol 2 AL1 At least 13 yrs old
haloperidol lactate (2 mg/ml conc, 10 mg/5 ml cup) 2 AL1 At least 13 yrs old
PHENOTHIAZINESchlorpromazine hcl (10 mg tablet, 25 mg tablet, 30 mg/mlconc, 50 mg tablet, 100 mg tablet, 100 mg/ml conc, 200mg tablet)
2 PA
fluphenazine hcl (1 mg tablet, 2.5 mg tablet, 5 mg tablet,10 mg tablet)
2 AL1 At least 13 yrs old
fluphenazine hcl (2.5 mg/5 ml elix, 5 mg/ml conc) 1 AL1 At least 13 yrs old
PAGE 48 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
perphenazine 1
thioridazine hcl 1 AL1 At least 13 yrs old
trifluoperazine hcl 2 AL1 At least 13 yrs old
THIOXANTHENES
thiothixene 1 AL1 At least 13 yrs old
ANTIRETROVIRALSHIV ENTRY AND FUSION INHIBITORS
FUZEON 5 S
RUKOBIA 3 PA
SELZENTRY (20 MG/ML ORAL SOLN, 25 MG TABLET, 75MG TABLET, 150 MG TABLET, 300 MG TABLET)
3
HIV INTEGRASE INHIBITOR ANTIRETROVIRALSISENTRESS 3
ISENTRESS HD 3
JULUCA 3
TIVICAY 3
TIVICAY PD 3
VOCABRIA 3
HIV NONNUCLEOSIDE REV.TRANSCRIP. INHIB.EDURANT 3
efavirenz (50 mg capsule, 600 mg tablet) 2
efavirenz 200 mg capsule 1
etravirine 2
INTELENCE 25 MG TABLET 3
nevirapine (50 mg/5 ml susp, 200 mg tablet) 2
nevirapine er 2
HIV NUCLEOSIDE, NUCLEOTIDE RT INHIBITORSabacavir (20 mg/ml solution, 300 mg tablet) 2
abacavir-lamivudine 1
PAGE 49 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
abacavir-lamivudine-zidovudine 2
BIKTARVY 3
COMPLERA 3
DESCOVY 3 ACA Affordable Care Act
efavirenz-emtric-tenofov disop 2
emtricitabine 2
emtricitabine-tenofovir disop (100-150mg, 133-200mg,167-250mg)
2
emtricitabine-tenofv 200-300mg 2 ACA Affordable Care Act
EPIVIR HBV 25 MG/5 ML SOLN 3
GENVOYA 3
lamivudine (10 mg/ml oral soln, 150 mg tablet, 300 mgtablet)
2
lamivudine hbv 2
lamivudine-zidovudine 2
ODEFSEY 3
STRIBILD 3
tenofovir disoproxil fumarate 1
TRIUMEQ 3
TRUVADA (100 MG-150 MG TABLET, 133 MG-200 MGTABLET, 167 MG-250 MG TABLET)
3
VIREAD (150 MG TABLET, 200 MG TABLET, 250 MGTABLET, POWDER)
3
zidovudine (50 mg/5 ml syrup, 300 mg tablet) 2
zidovudine 100 mg capsule 1
HIV PROTEASE INHIBITOR ANTIRETROVIRALSAPTIVUS (100 MG/ML SOLUTION, 250 MG CAPSULE) 3
atazanavir sulfate 2
EVOTAZ 3
fosamprenavir calcium 2
PAGE 50 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INVIRASE 3
KALETRA (100-25 MG TABLET, 200-50 MG TABLET) 3
LEXIVA 50 MG/ML SUSPENSION 3
lopinavir-ritonavir (lopinavir-ritonavir 80-20mg/ml,lopinavir-ritonavr 100-25mg tb, lopinavir-ritonavr 200-50mg tb)
2
NORVIR 80 MG/ML SOLUTION 3
PREZCOBIX 3
PREZISTA (75 MG TABLET, 100 MG/ML SUSPENSION, 150MG TABLET, 600 MG TABLET, 800 MG TABLET)
3
REYATAZ 50 MG POWDER PACKET 3
ritonavir 2
SYMTUZA 3
ANTITHROMBOTIC AGENTSANTITHROMBOTIC AGENTS, MISCELLANEOUS
CABLIVI 11 MG KIT 5PA
S
PLATELET-AGGREGATION INHIBITORSBRILINTA 3
cilostazol 2
clopidogrel 75 mg tablet 1
prasugrel hcl 2
ZONTIVITY 3 PA
PLATELET-REDUCING AGENTSanagrelide hcl 2
ANTITOXINS,IMMUNE GLOB,TOXOIDS,VACCINESALLERGENIC EXTRACTS (THERAPEUTIC)
GRASTEK 3 PA
ODACTRA 3 PA
PALFORZIA 5PA
S
PAGE 51 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RAGWITEK 3 PA
TOXOIDSADACEL TDAP 3
BOOSTRIX TDAP 3
DAPTACEL DTAP 3
diphtheria-tetanus toxoids-ped 3
INFANRIX DTAP 3
tdvax 3
TENIVAC SYRINGE 3
VAXELIS 3
VACCINESACTHIB 3
adenovirus type 4 3
adenovirus type 4 and type 7 3
adenovirus type 7 3
AFLURIA QUAD 2019-20 (3YR UP) 3 ACA Affordable Care Act
AFLURIA QUAD 2019-20 (6-35MO) 3 ACA Affordable Care Act
AFLURIA QUAD 2019-2020 3 ACA Affordable Care Act
AFLURIA QUAD 2020-2021 3 ACA Affordable Care Act
AFLURIA QUAD 2020-21 (3YR UP) 3 ACA Affordable Care Act
AFLURIA QUAD 2020-21 (6-35MO) 3 ACA Affordable Care Act
AFLURIA QUAD 2021-2022 3 ACA Affordable Care Act
AFLURIA QUAD 2021-22 (3YR UP) 3 ACA Affordable Care Act
AFLURIA QUAD 2021-22 (6-35MO) 3 ACA Affordable Care Act
ASTRAZENECA COVID19 VAC(UNAPP) 3
BEXSERO 3
COMIRNATY 3
PAGE 52 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ENGERIX-B ADULT 3
ENGERIX-B PEDIATRIC-ADOLESCENT 3
FLUAD 2019-2020 3 ACA Affordable Care Act
FLUAD 2020-2021 3 ACA Affordable Care Act
FLUAD QUAD 2020-2021 3 ACA Affordable Care Act
FLUAD QUAD 2021-2022 3 ACA Affordable Care Act
FLUARIX QUAD 2019-2020 3 ACA Affordable Care Act
FLUARIX QUAD 2020-2021 3 ACA Affordable Care Act
FLUARIX QUAD 2021-2022 3 ACA Affordable Care Act
FLUBLOK QUAD 2019-2020 3 ACA Affordable Care Act
FLUBLOK QUAD 2020-2021 3 ACA Affordable Care Act
FLUBLOK QUAD 2021-2022 3 ACA Affordable Care Act
FLUCELVAX QUAD 2019-2020 (SYR, VIAL) 3 ACA Affordable Care Act
FLUCELVAX QUAD 2020-2021 (SYR, VIAL) 3 ACA Affordable Care Act
FLUCELVAX QUAD 2021-2022 (SYR, VIAL) 3 ACA Affordable Care Act
FLULAVAL QUAD 2019-2020 (SYR, VIAL) 3 ACA Affordable Care Act
FLULAVAL QUAD 2020-2021 3 ACA Affordable Care Act
FLULAVAL QUAD 2021-2022 3 ACA Affordable Care Act
FLUMIST QUAD 2019-2020 3 ACA Affordable Care Act
FLUMIST QUAD 2020-2021 3 ACA Affordable Care Act
FLUMIST QUAD 2021-2022 3 ACA Affordable Care Act
FLUZONE HIGH-DOSE 2019-2020 3 ACA Affordable Care Act
FLUZONE HIGH-DOSE QUAD 2020-21 3 ACA Affordable Care Act
FLUZONE HIGH-DOSE QUAD 2021-22 3 ACA Affordable Care Act
PAGE 53 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FLUZONE QUAD 2019-2020 3 ACA Affordable Care Act
FLUZONE QUAD 2020-2021 3 ACA Affordable Care Act
FLUZONE QUAD 2021-2022 3 ACA Affordable Care Act
FLUZONE QUAD PEDI 2019-2020 3 ACA Affordable Care Act
FLUZONE QUAD SOUTHERN HEM 2020 (HEM2020 SYR,HEM 2020 VL)
3 ACA Affordable Care Act
FLUZONE QUAD SOUTHERN HEM 2021 (HEM2021 SYR,HEM 2021 VL)
3 ACA Affordable Care Act
GARDASIL 9 3
HAVRIX 3
HEPLISAV-B 3
HIBERIX 3
IPOL 3 ACA Affordable Care Act
JANSSEN COVID-19 VACCINE (EUA) 3
KINRIX 3
M-M-R II VACCINE 3 ACA Affordable Care Act
MENACTRA 3
MENQUADFI 3 ACA Affordable Care Act
MENVEO A-C-Y-W-135-DIP 3
MENVEO MENA COMPONENT 3 ACA Affordable Care Act
MENVEO MENCYW-135 COMPONENT 3 ACA Affordable Care Act
MODERNA COVID-19 VACCINE (EUA) 3
NOVAVAX COVID19 VAC,ADJ(UNAPP) 3
PEDIARIX 3
PEDVAXHIB 3
PENTACEL 3
PENTACEL ACTHIB COMPONENT 3
PENTACEL DTAP-IPV COMPONENT 3
PAGE 54 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PFIZER COVID-19 VACCINE (EUA) 3
PNEUMOVAX 23 3
PREVNAR 13 3
PREVNAR 20 3
PROQUAD 3
QUADRACEL DTAP-IPV 3 ACA Affordable Care Act
RECOMBIVAX HB (5 MCG/0.5 ML SYR, 10 MCG/ML SYR,40 MCG/ML VIAL)
3
RECOMBIVAX HB (5 MCG/0.5 ML VL, 10 MCG/ML VIAL) 3 ACA Affordable Care Act
ROTARIX 3
ROTATEQ 3
SHINGRIX 3 QL 1 KIT / RX
SHINGRIX GE ANTIGEN COMPONENT 3 QL 1 KIT / RX
TRUMENBA 3
TWINRIX 3
VAQTA (25 UNITS/0.5 ML SYRINGE, 50 UNITS/MLSYRINGE, 50 UNITS/ML VIAL)
3
VAQTA 25 UNITS/0.5 ML VIAL 3 ACA Affordable Care Act
VARIVAX VACCINE 3
VAXCHORA ACTIVE COMPONENT 3
VAXCHORA VACCINE 3
VAXNEUVANCE 3
VIVOTIF 3
ZOSTAVAX 3
ANTIULCER AGENTS AND ACID SUPPRESSANTSANTIULCER AGENTS AND ACID SUPPRESS.,MISC
TALICIA 3 PA
PAGE 55 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HISTAMINE H2-ANTAGONISTScimetidine (300 mg tablet, 300 mg/5 ml soln, 400 mgtablet, 400 mg/6.67 ml soln, 800 mg tablet)
2
famotidine (20 mg tablet, 40 mg tablet) 1
famotidine 40 mg/5 ml susp 2 AL1 Up to 12 yrs old
PROSTAGLANDINSmisoprostol 2
PROTECTANTSsucralfate 1 gm tablet 2
sucralfate 1 gm/10 ml susp 2 PA
PROTON-PUMP INHIBITORSesomeprazole magnesium (cvs 20 mg cap, dr 20 mg cap,dr 40 mg cap, gnp dr 20 mg, gs dr 20 mg, hm dr 20 mg, qcdr 20 mg, ra dr 20 mg, sm dr 20 mg)
2
lansoprazole (dr 15 mg capsule, dr 30 mg capsule) 2
lansoprazole (odt 15 mg tablet, odt 30 mg tablet) 2 AL1 Up to 9 yrs old
omeprazole (dr 10 mg capsule, dr 20 mg capsule, dr 40mg capsule)
2
pantoprazole sodium (dr 20 mg tab, dr 40 mg tab) 1
rabeprazole sod dr 20 mg tab 2
ANTIVIRALS (SYSTEMIC)ADAMANTANE ANTIVIRALS
rimantadine hcl 2
ANTIVIRALS, MISCELLANEOUSPREVYMIS (240 MG TABLET, 480 MG TABLET) 3
TPOXX (NATIONAL STOCKPILE) 3 PA
INTERFERON ANTIVIRALS
ALFERON N 5 S
INTRON A (10 MILLION UNITS VIL, 18 MILLION UNIT/3 ML,18 MILLION UNITS VIL, 25 MILLION UNIT/2.5ML, 50MILLION UNITS VIL)
5 S
PAGE 56 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PEGASYS 5PA
S
PEGASYS PROCLICK 5PA
S
PEGINTRON 5PA
S
SYLATRON 3S
ONC Oncology
NEURAMINIDASE INHIBITOR ANTIVIRALS
oseltamivir 6 mg/ml suspension 2 QL 180 ML / 1 FILL
oseltamivir phos 30 mg capsule 2 QL 20 CAPS / 1 FILL
oseltamivir phosphate (45 mg capsule, 75 mg capsule) 2 QL 10 CAPS / 1 FILL
RELENZA 3 QL 20 CAPS / 1 FILL
NUCLEOSIDE AND NUCLEOTIDE ANTIVIRALSacyclovir (200 mg capsule, 400 mg tablet, 800 mg tablet) 2
acyclovir 200 mg/5 ml susp 2 AL1 Up to 12 yrs old
adefovir dipivoxil 2
BARACLUDE 0.05 MG/ML SOLUTION 3
entecavir 1
famciclovir 2
ribavirin (200 mg capsule, 200 mg tablet) 5 S
valacyclovir 2
valganciclovir hcl (hcl 50 mg/ml, 450 mg tablet) 2
VEMLIDY 3
ANXIOLYTICS, SEDATIVES AND HYPNOTICSANXIOLYTICS,SEDATIVES,AND HYPNOTICS,MISC
buspirone hcl 2
eszopiclone 2
PAGE 57 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
hydroxyzine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet) 1
hydroxyzine hcl (10 mg/5 ml soln, 10 mg/5 ml syrup, 50mg/25 ml syrup)
2
hydroxyzine pamoate 2
ramelteon 2 QL 1 TAB / 1 DAY
zaleplon 2
zolpidem tartrate (5 mg tablet, 10 mg tablet) 1
BARBITURATES (ANXIOLYTIC, SEDATIVE/HYP)phenobarbital (15 mg tablet, 16.2 mg tablet, 20 mg/5 mlelix, 20 mg/5 ml soln, 30 mg tablet, 60 mg tablet, 100 mgtablet)
2
BENZODIAZEPINES (ANXIOLYTIC,SEDATIV/HYP)
alprazolam (0.25 mg tablet, 0.5 mg tablet, 1 mg tablet) 1 QL 6 TABS / 1 DAY
alprazolam 2 mg tablet 1 QL 3 TABS / 1 DAY
alprazolam er (er 0.5 mg tablet, er 1 mg tablet) 1 QL 6 TABS / 1 DAY
alprazolam er 2 mg tablet 1 QL 3 TABS / 1 DAY
alprazolam er 3 mg tablet 1 QL 2 TABS / 1 DAY
alprazolam xr (0.5 mg tablet, 1 mg tablet) 1 QL 6 TABS / 1 DAY
alprazolam xr 2 mg tablet 1 QL 3 TABS / 1 DAY
alprazolam xr 3 mg tablet 1 QL 2 TABS / 1 DAY
chlordiazepoxide 10 mg capsule 1 QL 6 CAPS / 1 DAY
chlordiazepoxide 25 mg capsule 1 QL 4 CAPS / 1 DAY
chlordiazepoxide 5 mg capsule 2 QL 6 CAPS / 1 DAY
diazepam (2 mg tablet, 5 mg tablet) 1 QL 6 TABS / 1 DAY
diazepam (2.5 mg rectal gel sys, 10 mg rectal gel syst, 20mg rectal gel syst)
2 QL 4 KIT / 30 DAYS
diazepam 10 mg tablet 1 QL 4 TABS / 1 DAY
diazepam 5 mg/5 ml solution 2 QL 40 ML / 1 DAY
PAGE 58 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
diazepam 5 mg/ml oral conc 2 QL 8 ML / 1 DAY
lorazepam (0.5 mg tablet, 1 mg tablet) 1 QL 6 TABS / 1 DAY
lorazepam 2 mg tablet 1 QL 5 TABS / 1 DAY
lorazepam 2 mg/ml oral concent 2 QL 5 ML / 1 DAY
LORAZEPAM INTENSOL 2 QL 5 ML / 1 DAY
temazepam 15 mg capsule 1 QL 2 CAPS / 1 DAY
temazepam 30 mg capsule 1 QL 1 CAP / 1 DAY
VALTOCO 3QL 1 CARTON / RX
PA
AUTONOMIC DRUGSAUTONOMIC DRUGS, MISCELLANEOUS
CHANTIX 3QL 2 TABS / 1 DAY
SC Smoking Cessation
nicotine gum 2 SC Smoking Cessation
nicotine lozenge (2 mg lozenge, 2 mg mini lozenge, cvs 2mg lozenge, eq 2 mg lozenge, eql 2 mg lozenge, gnp 2 mglozenge, hm 2 mg lozenge, kro 2 mg lozenge, ra 2 mglozenge, sm 2 mg lozenge, sw 2 mg lozenge, 4 mglozenge, 4 mg mini lozenge, cvs 4 mg lozenge, eq 4 mglozenge, eql 4 mg lozenge, gnp 4 mg lozenge, gs 4 mglozenge, hm 4 mg lozenge, kro 4 mg lozenge, ra 4 mglozenge, sm 4 mg lozenge, sw 4 mg lozenge)
2 SC Smoking Cessation
PAGE 59 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSnicotine patch (7 mg/24hr patch, cvs 7 mg/24hr patch, eq7 mg/24hr patch, hm 7 mg/24hr patch, kro 7 mg/24hrpatch, ra 7 mg/24hr patch, sm 7 mg/24hr patch, 14mg/24hr patch, cvs 14 mg/24hr patch, gnp 7 mg/24hrpatch, hm 14 mg/24hr patch, qc 14 mg/24hr patch, ra 14mg/24hr patch, 21 mg/24hr patch, cvs 21 mg/24hr patch,eq 14 mg/24hr patch, eq 21 mg/24hr patch, gnp 14mg/24hr patch, gnp 21 mg/24hr patch, hm 21 mg/24hrpatch, kro 14 mg/24hr patch, kro 21 mg/24hr patch, qc 21mg/24hr patch, ra 21 mg/24hr patch, sm 14 mg/24hrpatch, sm 21 mg/24hr patch)
2 SC Smoking Cessation
NICOTROL 3 SC Smoking Cessation
NICOTROL NS 3 SC Smoking Cessation
varenicline tartrate 2
QL 2 TABS / 1 DAY
ACA Affordable Care Act
SC Smoking Cessation
PARASYMPATHOMIMETIC (CHOLINERGIC AGENTS)bethanechol chloride 2
cevimeline hcl 2
donepezil hcl (5 mg tablet, 10 mg tablet) 2
donepezil hcl odt 2
galantamine er 2
galantamine hbr 2
galantamine hydrobromide 2
pilocarpine hcl (5 mg tablet, 7.5 mg tablet) 2
pyridostigmine br 30 mg tablet 2 QL 1 TAB / 1 DAY
pyridostigmine br 60 mg tablet 2
pyridostigmine bromide er 2 PA
rivastigmine (1.5 mg capsule, 3 mg capsule, 4.5 mgcapsule, 4.6 mg/24hr patch, 6 mg capsule, 9.5 mg/24hrpatch, 13.3 mg/24hr ptch)
2
PAGE 60 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
BETA-3-ADRENERGIC AGONISTSSELECTIVE BETA-3-ADRENERGIC AGONISTS
MYRBETRIQ (ER 25 MG TABLET, ER 50 MG TABLET) 3
BETA-ADRENERGIC AGONISTSSELECTIVE BETA-2-ADRENERGIC AGONISTS
albuterol sulfate (sul 0.63 mg/3 ml sol, sul 1.25 mg/3 mlsol, 2.5 mg/0.5 ml sol, sul 2.5 mg/3 ml soln, sulf 2 mg/5ml syrup, 5 mg/ml solution, 100 mg/20 ml soln)
2
levalbuterol tartrate hfa 2
SEREVENT DISKUS 3
STRIVERDI RESPIMAT 3
VENTOLIN HFA 2
BLOOD FORMATION, COAGULATION, THROMBOSISBLOOD FORM.,COAG,THROMBOSIS AGENTS MISC.
OXBRYTA 5
QL 3 TABS / 1 DAY
PA
S
HEMATOPOIETIC AGENTS
ARANESP 5 S
FULPHILA 3
GRANIX 3 S
NYVEPRIA 3
PROMACTA (12.5 MG TABLET, 25 MG TABLET, 50 MGTABLET, 75 MG TABLET)
5PA
S
PROMACTA 12.5 MG SUSPEN PACKET 5
QL 1 PACKET / 1 DAY
PA
S
PROMACTA 25 MG SUSPENSION PCKT 5
QL 3 PACKETS / 1 DAY
PA
S
PAGE 61 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONSRETACRIT (2,000 UNIT/ML VIAL, 3,000 UNIT/ML VIAL,4,000 UNIT/ML VIAL, 10,000 UNIT/ML VIAL, 20,000UNIT/ML VIAL, 40,000 UNIT/ML VIAL)
5 S
UDENYCA 3
ZIEXTENZO 3
HEMORRHEOLOGIC AGENTSpentoxifylline 2
CALCIUM-CHANNEL BLOCKING AGENTSCALCIUM-CHANNEL BLOCKING AGENTS, MISC.
CARTIA XT 2
DILT-XR 1
diltiazem 24hr er (24hr er 120 mg cap, 24hr er 180 mgcap, 24hr er 240 mg cap, 24hr er 300 mg cap, 24hr er 420mg cap)
2
diltiazem 24hr er (cd) (24h 120 mg cp, 24h 180 mg cp, 24h240 mg cp, 24h 300 mg cp)
2
diltiazem 24hr er (xr) 1
diltiazem 24hr er 360 mg cap 1
diltiazem hcl (30 mg tablet, 60 mg tablet, 90 mg tablet,120 mg tablet)
2
MATZIM LA 240 MG TABLET 1
TAZTIA XT (120 MG CAPSULE, 180 MG CAPSULE, 240 MGCAPSULE, 300 MG CAPSULE)
2
TAZTIA XT 360 MG CAPSULE 1
TIADYLT ER (ER 180 MG CAPSULE, ER 420 MG CAPSULE) 2
verapamil 360 mg cap pellet 2
verapamil er (er 120 mg capsule, er 180 mg capsule, er240 mg capsule)
1
verapamil er (er 120 mg tablet, er 180 mg tablet, er 240mg tablet)
2
verapamil hcl (40 mg tablet, 80 mg tablet, 120 mg tablet) 1
verapamil sr 1
PAGE 62 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DIHYDROPYRIDINESamlodipine besylate 1
amlodipine besylate-benazepril 2
amlodipine-olmesartan 2
amlodipine-valsartan 1
amlodipine-valsartan-hctz 2
felodipine er 2
nifedipine 2 AL1 Up to 45 yrs old
nifedipine er 2
nimodipine 2
CARDIAC DRUGSCARDIAC DRUGS, MISCELLANEOUS
CORLANOR (5 MG TABLET, 5 MG/5 ML ORAL SOLN, 7.5MG TABLET)
3 PA
VYNDAMAX 5PA
S
VYNDAQEL 5PA
S
CARDIOTONIC AGENTSDIGITEK 125 MCG TABLET 2
DIGITEK 250 MCG TABLET 2 AL1 Up to 64 yrs old
DIGOX 125 MCG TABLET 2
DIGOX 250 MCG TABLET 2 AL1 Up to 64 yrs old
digoxin (0.125 mg tablet, 125 mcg tablet) 2
digoxin (0.25 mg tablet, 250 mcg tablet) 2 AL1 Up to 64 yrs old
digoxin 0.05 mg/ml solution 3
PAGE 63 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CARDIOVASCULAR DRUGSALPHA-ADRENERGIC BLOCKING AGENTS
doxazosin mesylate 2
prazosin hcl 2
terazosin hcl 1
BETA-ADRENERGIC BLOCKING AGENTSacebutolol hcl 2
atenolol 1
atenolol-chlorthalidone 2
betaxolol hcl (10 mg tablet, 20 mg tablet) 2
bisoprolol fumarate 2
bisoprolol-hydrochlorothiazide 1
carvedilol 1
labetalol hcl (100 mg tablet, 200 mg tablet, 300 mgtablet)
2
metoprolol succinate 2
metoprolol tartrate (25 mg tab, 50 mg tab, 100 mg tab) 1
metoprolol-hydrochlorothiazide 2
nadolol 1
propranolol hcl (10 mg tablet, 20 mg tablet, 20 mg/5 mlsoln, 40 mg tablet, 40 mg/5 ml soln, 60 mg tablet, 80 mgtablet)
2
propranolol hcl er 1
propranolol-hydrochlorothiazid 2
sotalol 2
SOTALOL AF 2
timolol maleate (5 mg tablet, 10 mg tablet, 20 mg tablet) 2
PAGE 64 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CENTRAL NERVOUS SYSTEM AGENTSANTIMANIC AGENTS
lithium 2
lithium carbonate 2
lithium carbonate er 2
CENTRAL NERVOUS SYSTEM AGENTS, MISC.acamprosate calcium 2
atomoxetine hcl (10 mg capsule, 18 mg capsule, 25 mgcapsule, 40 mg capsule)
2 QL 2 CAPS / 1 DAY
atomoxetine hcl (60 mg capsule, 80 mg capsule, 100 mgcapsule)
2 QL 1 CAP / 1 DAY
guanfacine hcl er (er 3 mg tablet, er 4 mg tablet) 2 QL 1 TAB / 1 DAY
guanfacine hcl er 1 mg tablet 2 QL 3 TABS / 1 DAY
guanfacine hcl er 2 mg tablet 2 QL 2 TABS / 1 DAY
memantine hcl (hcl 2 mg/ml solution, 5-10 mg titrationpk, hcl 5 mg tablet, hcl 10 mg tablet)
2
NOURIANZ 5PA
S
riluzole 2
XYREM 5
QL 18 ML / 1 DAY
PA
S
XYWAV 5
QL 18 ML / 1 DAY
PA
S
OPIATE ANTAGONISTSKLOXXADO 3
naloxone 2 mg/2 ml syringe 2
naltrexone hcl 2
NARCAN 3
PAGE 65 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VESICULAR MONOAMINE TRANSPORT2 INHIBITOR
AUSTEDO 5PA
S
INGREZZA 5PA
S
INGREZZA INITIATION PACK 5PA
S
tetrabenazine 5PA
S
CEPHALOSPORIN ANTIBIOTICS1ST GENERATION CEPHALOSPORIN ANTIBIOTICS
cefadroxil (1 gm tablet, 250 mg/5 ml susp, 500 mg/5 mlsusp)
1
cefadroxil 500 mg capsule 2
cephalexin (125 mg/5 ml susp, 250 mg/5 ml susp) 2
cephalexin (250 mg capsule, 500 mg capsule) 1
2ND GENERATION CEPHALOSPORIN ANTIBIOTICScefprozil (125 mg/5 ml susp, 250 mg/5 ml susp) 1
cefprozil (250 mg tablet, 500 mg tablet) 2
cefuroxime 2
3RD GENERATION CEPHALOSPORIN ANTIBIOTICScefdinir (125 mg/5 ml susp, 250 mg/5 ml susp) 2
cefdinir 300 mg capsule 1
cefixime 400 mg capsule 2 QL 1 CAP / 30 DAYS
cefpodoxime proxetil (100 mg tablet, 200 mg tablet) 2QL 14 TABS / RX
PA
cefpodoxime proxetil (50 mg/5 ml susp, 100 mg/5 mlsusp)
2QL 100 ML / RX
PA
PAGE 66 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CORTICOSTEROIDS (RESPIRATORY TRACT)ORALLY INHALED PREPARATIONS (STEROIDS)
ADVAIR DISKUS 2
ADVAIR HFA 3
ARNUITY ELLIPTA 3
ASMANEX (TWISTHALER 110 MCG #30, TWISTHALER 220MCG #30, TWISTHALER 220 MCG #60, TWISTHALR 220MCG #120)
3
ASMANEX HFA 3
BREO ELLIPTA 3
budesonide (0.25 mg/2 ml susp, 0.5 mg/2 ml susp, 1 mg/2ml inh susp)
2
budesonide-formoterol fumarate 2
DULERA 3 PA
FLOVENT DISKUS 3
FLOVENT HFA 3
fluticasone-salmeterol 113-14 (generic for airduorespiclick)
2
fluticasone-salmeterol 232-14 (generic for airduorespiclick)
2
fluticasone-salmeterol 55-14 (generic for airduo respiclick) 2
PULMICORT FLEXHALER 3
QVAR REDIHALER 3
TRELEGY ELLIPTA 3
CYSTIC FIBROSIS (CFTR) MODULATORSCYSTIC FIBROSIS (CFTR) CORRECTORS
SYMDEKO 5PA
S
TRIKAFTA 5PA
S
PAGE 67 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CYSTIC FIBROSIS (CFTR) POTENTIATORS
KALYDECO 5PA
S
ORKAMBI 5PA
S
DIAGNOSTIC AGENTSADRENOCORTICAL INSUFFICIENCY
ACTHAR 5PA
S
DIURETICSLOOP DIURETICS
bumetanide (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 2
furosemide (10 mg/ml solution, 20 mg tablet, 40 mgtablet, 40 mg/5 ml soln, 80 mg tablet)
1
torsemide 2
POTASSIUM-SPARING DIURETICSamiloride hcl 2
amiloride-hydrochlorothiazide 2
triamterene-hydrochlorothiazid 1
THIAZIDE DIURETICShydrochlorothiazide 1
THIAZIDE-LIKE DIURETICSchlorthalidone 2
indapamide 2
metolazone 2
DOPAMINE RECEPTOR AGONISTSERGOT-DERIV. DOPAMINE RECEPTOR AGONISTS
bromocriptine mesylate 2
cabergoline 2
CYCLOSET 3 PA
PAGE 68 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NONERGOT-DERIV.DOPAMINE RECEPTOR AGONIST
NEUPRO 3 PA
pramipexole dihydrochloride 2
ropinirole hcl 2
ELECTROLYTIC, CALORIC, AND WATER BALANCEALKALINIZING AGENTS
potassium citrate er 2
AMMONIA DETOXICANTS
CARBAGLU 5PA
S
ENULOSE 2
GENERLAC 2
lactulose 10 gm/15 ml solution 2
sodium phenylbutyrate powder 2 PA
CALORIC AGENTS
DOJOLVI 5PA
S
levocarnitine 330 mg tablet 1
REPLACEMENT PREPARATIONSKLOR-CON M10 2
KLOR-CON M15 2
KLOR-CON M20 2
potassium chloride (er 8 meq capsule, er 8 meq tablet,10% (20 meq/15ml), 10% (40 meq/30ml), er 10 meqcapsule, er 10 meq tablet, 20 meq packet, 20% (40meq/15ml), er 20 meq tablet)
2
URICOSURIC AGENTSprobenecid 2
probenecid-colchicine 2
PAGE 69 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
EMOLLIENTS, DEMULCENTS, AND PROTECTANTSBASIC LOTIONS AND LINIMENTS
ammonium lactate 12% lotion 2
BASIC OINTMENTS AND PROTECTANTSammonium lactate 12% cream 2
ENZYMES
REVCOVI 5PA
S
STRENSIQ 5PA
S
SUCRAID 5PA
S
ESTROGENS AND ANTIESTROGENSESTROGEN AGONIST-ANTAGONISTS
raloxifene hcl 2 ACA Affordable Care Act
SOLTAMOX 3
tamoxifen citrate 2 ACA Affordable Care Act
ESTROGENSAMABELZ 0.5 MG-0.1 MG TABLET 2
DOTTI 2
estradiol (0.01% cream, 10 mcg vaginal insrt) 2
estradiol (0.5 mg tablet, 1 mg tablet, 2 mg tablet) 1
estradiol (once weekly) 2
estradiol (twice weekly) 2
estradiol-noreth 0.5-0.1 mg tb 2
FYAVOLV 1 MG-5 MCG TABLET 2
JINTELI 2
LOPREEZA 0.5 MG-0.1 MG TABLET 2
MIMVEY LO 2
PAGE 70 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
norethin-eth estrad 1 mg-5 mcg 2
PREMARIN VAGINAL CREAM-APPL 3
PREMPRO 3
YUVAFEM 2
EYE, EAR, NOSE AND THROAT (EENT) PREPS.ANTIALLERGIC AGENTS
azelastine hcl (hcl 0.05% drops, 0.1% (137 mcg) spry) 2
epinastine hcl 2
olopatadine hcl 0.1% eye drops 2
EENT DRUGS, MISCELLANEOUS
CYSTADROPS 5
QL 5 ML / RX
PA
S
CYSTARAN 5
QL 15 ML / RX
PA
S
ipratropium bromide (0.03% spray, 0.06% spray) 2
OXERVATE 5
QL 1 ML / 1 DAY
PA
S
LOCAL ANESTHETICS (EENT)lidocaine hcl (2% jel urojet ac, 2% jelly, 2% jelly uro-jet, 4%solution)
2
lidocaine hcl viscous 2
MYDRIATICSatropine sulfate (drops, ointment) 2
cyclopentolate hcl (drop, drops) 2
homatropaire 2
homatropine hydrobromide 2
PAGE 71 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VASOCONSTRICTORSphenylephrine hcl (2.5% drop, 10% drops) 2
FIRST GENERATION ANTIHISTAMINESFIRST GEN. ANTIHIST. DERIVATIVES, MISC.
cyproheptadine hcl (2 mg/5 ml soln, 2 mg/5 ml syrup, 4mg tablet, 4 mg/10 ml syrp)
2
PHENOTHIAZINE DERIVATIVESPHENADOZ 2
promethazine hcl (12.5 mg suppos, 25 mg suppository, 50mg suppository)
2
promethazine hcl (12.5 mg tablet, 25 mg tablet, 50 mgtablet)
2 AQ1 Up to 64 yrs old; 30 /1 FILL
promethazine hcl (6.25 mg/5 ml soln, 6.25 mg/5 ml syrp) 1 AQ1 Up to 64 yrs old; 300/ 1 FILL
promethazine vc 1
promethazine-phenylephrine 1
PROMETHEGAN 2
GASTROINTESTINAL DRUGSANTI-INFLAMMATORY AGENTS (GI DRUGS)
alosetron hcl 2 PA
balsalazide disodium 2
mesalamine (dr 1.2 gm tablet, 4 gm/60 ml enema, 800mg dr tablet, 1,000 mg supp)
2
mesalamine dr 2
mesalamine er 2
ANTIDIARRHEA AGENTS
diphenoxylat-atrop 2.5-0.025/5 2 QL 40 ML / 1 DAY
diphenoxylate-atrop 2.5-0.025 2 QL 8 TABS / 1 DAY
paregoric 2 QL 40 ML / 1 DAY
XERMELO 5PA
S
PAGE 72 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
CATHARTICS AND LAXATIVESGAVILYTE-C 2
GAVILYTE-G 2 ACA Affordable Care Act
GAVILYTE-N 2
lubiprostone 2 QL 2 CAPS / 1 DAY
peg 3350-electrolyte (3350 electrolyte soln, 3350-electrolyte solution)
2
SUPREP 3 ACA Affordable Care Act
TRILYTE WITH FLAVOR PACKETS 2
CHOLELITHOLYTIC AGENTSursodiol (250 mg tablet, 300 mg capsule, 500 mg tablet) 2
DIGESTANTSCREON 3
GI DRUGS, MISCELLANEOUS
ALLI 3PA
WL Weight Loss
CHOLBAM 5PA
S
ENDARI 5PA
S
HUMIRA(CF) PEDI CROHN 80-40 MG 5
QL 2 SYRINGES / 28DAYS
PA
S
LINZESS 3 QL 1 CAP / 1 DAY
MOVANTIK 3QL 1 TAB / 1 DAY
PA
SYMPROIC 3 PA
XENICAL 3PA
WL Weight Loss
PAGE 73 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PROKINETIC AGENTS
GIMOTI 3 PA
metoclopramide hcl (5 mg tablet, 5 mg/5 ml soln, 10 mgtablet, 10 mg/10 ml sol)
1
metoclopramide hcl odt 2 PA
GENITOURINARY SMOOTH MUSCLE RELAXANTSANTIMUSCARINICS
oxybutynin 5 mg tablet 1
oxybutynin 5 mg/5 ml syrup 2
oxybutynin chloride er 2
solifenacin succinate 2
tolterodine tartrate 2
tolterodine tartrate er 2
trospium chloride 1
GOLD COMPOUNDSRIDAURA 3
GONADOTROPINS AND ANTIGONADOTROPINSANTIGONADTROPINS
MYFEMBREE 5
QL 28 TABS / 28 DAYS
PA
S
ORGOVYX 3PA
S
ORIAHNN 5
QL 2 CAPS / 1 DAY
PA
S
ORILISSA 150 MG TABLET 5
QL 1 TAB / 1 DAY
PA
S
ORILISSA 200 MG TABLET 5
QL 56 TABS / 28 DAYS
PA
S
PAGE 74 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HCV ANTIVIRALSHCV POLYMERASE INHIBITOR ANTIVIRALS
EPCLUSA 200 MG-50 MG TABLET 5PA
S
HARVONI (33.75-150 MG PELLET PK, 45-200 MG PELLETPACKT, 45-200 MG TABLET)
5PA
S
ledipasvir-sofosbuvir 5PA
S
sofosbuvir-velpatasvir 5PA
S
SOVALDI (150 MG PELLET PACKET, 200 MG PELLETPACKET, 200 MG TABLET)
5PA
S
VOSEVI 5PA
S
HCV PROTEASE INHIBITOR ANTIVIRALS
MAVYRET 5PA
S
HEAVY METAL ANTAGONISTSCHEMET 3
D-PENAMINE 2 PA
deferasirox (90 mg tablet, 125 mg tb for susp, 180 mgtablet, 250 mg tb for susp, 500 mg tb for susp)
5
PA
S
TD Trial Drug
deferiprone 5PA
S
FERRIPROX (100 MG/ML SOLUTION, 1,000 MG TABLET) 5PA
S
FERRIPROX (2 TIMES A DAY) 5PA
S
PAGE 75 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
FERRIPROX (3 TIMES A DAY) 5PA
S
penicillamine 250 mg tablet 5PA
S
HORMONES AND SYNTHETIC SUBSTITUTESADRENALS
budesonide ec 2
dexamethasone (0.5 mg tablet, 0.75 mg tablet, 1 mgtablet, 1.5 mg tablet, 4 mg tablet, 6 mg tablet)
1
dexamethasone (0.5 mg/5 ml elx, 0.5 mg/5 ml liq, 2 mgtablet)
2
DEXAMETHASONE INTENSOL 3
dexamethasone sodium phosphate (10 mg/ml syring, 10mg/ml vial, 100 mg/10 ml vl)
2
dexamethasone sodium phosphate (4 mg/ml vial, 20mg/5 ml vial, 120 mg/30 ml vl)
1
fludrocortisone acetate 2
hydrocortisone (5 mg tablet, 10 mg tablet, 20 mg tablet) 2
MEDROL 2 MG TABLET 3
methylprednisolone 2
MILLIPRED 3
prednisolone 1
prednisolone sodium phosphate (5 mg/5 ml soln, 15 mg/5ml soln, sod ph 25 mg/5 ml)
1
prednisone (1 mg tablet, 2.5 mg tablet, 5 mg tab dosepack, 5 mg tablet, 10 mg tab dose pack, 10 mg tablet, 20mg tablet, 50 mg tablet)
1
prednisone 5 mg/5 ml solution 2
PREDNISONE INTENSOL 3
SOLU-CORTEF 100 MG ACT-O-VIAL 3
PAGE 76 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ANDROGENSdanazol 2
methyltestosterone 2QL 5 CAPS / 1 DAY
PA
oxandrolone 10 mg tablet 2QL 2 TABS / 1 DAY
PA
oxandrolone 2.5 mg tablet 2QL 4 TABS / 1 DAY
PA
testosterone (1% (25mg/2.5g) pk, 1% (50 mg/5 g) pk,1.62% (2.5 g) pkt, 1.62% gel pump, 1.62%(1.25 g) pkt, 10mg gel pump, 12.5 mg/1.25 gram, 50 mg/5 gram gel, 50mg/5 gram pkt)
2 PA
testosterone cypionate (testosteron 1,000 mg/10 ml,testosteron 2,000 mg/10 ml, testosterone 100 mg/ml,testosterone 200 mg/ml, testosterone 500 mg/2.5 ml,testosterone 500 mg/5 ml, testosterone 1,000 mg/5 ml,testosterone 6,000 mg/30ml)
2 PA
testosterone enanthate 2 PA
testosterone propionate 2 PA
CONTRACEPTIVES
AFIRMELLE 2 ACA Affordable Care Act
ALTAVERA 2 ACA Affordable Care Act
ALYACEN 2 ACA Affordable Care Act
AMETHIA 2 ACA Affordable Care Act
AMETHIA LO 2 ACA Affordable Care Act
APRI 2 ACA Affordable Care Act
ARANELLE 2 ACA Affordable Care Act
ASHLYNA 2 ACA Affordable Care Act
AUBRA 2 ACA Affordable Care Act
PAGE 77 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AUBRA EQ 2 ACA Affordable Care Act
AUROVELA 2 ACA Affordable Care Act
AUROVELA 24 FE 2 ACA Affordable Care Act
AUROVELA FE 2 ACA Affordable Care Act
AVIANE 2 ACA Affordable Care Act
AYUNA 2 ACA Affordable Care Act
AZURETTE 2 ACA Affordable Care Act
BALZIVA 2 ACA Affordable Care Act
BEKYREE 2 ACA Affordable Care Act
BLISOVI 24 FE 3 ACA Affordable Care Act
BLISOVI FE 2 ACA Affordable Care Act
BRIELLYN 2 ACA Affordable Care Act
CAMILA 2 ACA Affordable Care Act
CAMRESE 2 ACA Affordable Care Act
CAMRESE LO 2 ACA Affordable Care Act
CAZIANT 2 ACA Affordable Care Act
CHATEAL 2 ACA Affordable Care Act
CHATEAL EQ 2 ACA Affordable Care Act
CRYSELLE 2 ACA Affordable Care Act
CYCLAFEM 2 ACA Affordable Care Act
CYRED 2 ACA Affordable Care Act
CYRED EQ 2 ACA Affordable Care Act
DASETTA 2 ACA Affordable Care Act
DAYSEE 2 ACA Affordable Care Act
PAGE 78 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
DEBLITANE 2 ACA Affordable Care Act
desogestr-eth estrad eth estra 2 ACA Affordable Care Act
desogestrel-ethinyl estradiol 2 ACA Affordable Care Act
drospirenone-ethinyl estradiol 2 ACA Affordable Care Act
ELINEST 2 ACA Affordable Care Act
ELLA 3 ACA Affordable Care Act
ELURYNG 2 ACA Affordable Care Act
EMOQUETTE 2 ACA Affordable Care Act
ENPRESSE 2 ACA Affordable Care Act
ENSKYCE 2 ACA Affordable Care Act
ERRIN 2 ACA Affordable Care Act
ESTARYLLA 2 ACA Affordable Care Act
ethynodiol-ethinyl estradiol 2 ACA Affordable Care Act
etonogestrel-ethinyl estradiol 2 ACA Affordable Care Act
FALMINA 2 ACA Affordable Care Act
FEMYNOR 2 ACA Affordable Care Act
GIANVI 2 ACA Affordable Care Act
HAILEY 2 ACA Affordable Care Act
HAILEY FE 2 ACA Affordable Care Act
HEATHER 2 ACA Affordable Care Act
ICLEVIA 2 ACA Affordable Care Act
INCASSIA 2 ACA Affordable Care Act
INTROVALE 2 ACA Affordable Care Act
ISIBLOOM 2 ACA Affordable Care Act
PAGE 79 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
JAIMIESS 2 ACA Affordable Care Act
JASMIEL 2 ACA Affordable Care Act
JENCYCLA 2 ACA Affordable Care Act
JOLESSA 2 ACA Affordable Care Act
JULEBER 2 ACA Affordable Care Act
JUNEL 2 ACA Affordable Care Act
JUNEL FE 2 ACA Affordable Care Act
KALLIGA 2 ACA Affordable Care Act
KARIVA 2 ACA Affordable Care Act
KELNOR 1-35 2 ACA Affordable Care Act
KELNOR 1-50 2 ACA Affordable Care Act
KURVELO 2 ACA Affordable Care Act
LARIN 2 ACA Affordable Care Act
LARIN FE 2 ACA Affordable Care Act
LARISSIA 2 ACA Affordable Care Act
LEENA 2 ACA Affordable Care Act
LESSINA 2 ACA Affordable Care Act
LEVONEST 2 ACA Affordable Care Act
levonorg-eth estrad eth estrad (levono-e 0.15-0.03-0.01,levonor-e 0.1-0.02-0.01)
2 ACA Affordable Care Act
levonorgestrel 2 ACA Affordable Care Act
levonorgestrel-eth estradiol (0.1-0.02 mg, 0.15-0.03,triphasic)
2 ACA Affordable Care Act
LEVORA-28 2 ACA Affordable Care Act
LILLOW 2 ACA Affordable Care Act
PAGE 80 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
LO-ZUMANDIMINE 2 ACA Affordable Care Act
LOJAIMIESS 2 ACA Affordable Care Act
LORYNA 2 ACA Affordable Care Act
LOW-OGESTREL 2 ACA Affordable Care Act
LUTERA 2 ACA Affordable Care Act
LYZA 2 ACA Affordable Care Act
MARLISSA 2 ACA Affordable Care Act
MICROGESTIN 2 ACA Affordable Care Act
MICROGESTIN FE 2 ACA Affordable Care Act
MILI 2 ACA Affordable Care Act
MONO-LINYAH 2 ACA Affordable Care Act
MY WAY 2 ACA Affordable Care Act
NECON 2 ACA Affordable Care Act
NIKKI 2 ACA Affordable Care Act
NORA-BE 2 ACA Affordable Care Act
norethindron-ethinyl estradiol (norethin-ee 1.5-0.03mg(21) tb, norethind-eth estrad 1-0.02 mg)
2 ACA Affordable Care Act
norethindrone 2 ACA Affordable Care Act
norethindrone-e.estradiol-iron (1-0.02(21)-75 tab, 1.5-0.03mg(21)-75)
2 ACA Affordable Care Act
norgestimate-ethinyl estradiol 2 ACA Affordable Care Act
NORLYDA 2 ACA Affordable Care Act
NORTREL 2 ACA Affordable Care Act
NYMYO 2 ACA Affordable Care Act
OCELLA 2 ACA Affordable Care Act
PAGE 81 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
OGESTREL 2 ACA Affordable Care Act
ORSYTHIA 2 ACA Affordable Care Act
PHILITH 2 ACA Affordable Care Act
PIMTREA 2 ACA Affordable Care Act
PIRMELLA 2 ACA Affordable Care Act
PORTIA 2 ACA Affordable Care Act
PREVIFEM 2 ACA Affordable Care Act
RECLIPSEN 2 ACA Affordable Care Act
SETLAKIN 2 ACA Affordable Care Act
SHAROBEL 2 ACA Affordable Care Act
SIMLIYA 2 ACA Affordable Care Act
SIMPESSE 2 ACA Affordable Care Act
SPRINTEC 2 ACA Affordable Care Act
SRONYX 2 ACA Affordable Care Act
SYEDA 2 ACA Affordable Care Act
TARINA 24 FE 2 ACA Affordable Care Act
TARINA FE 2 ACA Affordable Care Act
TARINA FE 1-20 EQ 2 ACA Affordable Care Act
TILIA FE 2 ACA Affordable Care Act
TRI FEMYNOR 2 ACA Affordable Care Act
TRI-ESTARYLLA 2 ACA Affordable Care Act
TRI-LEGEST FE 2 ACA Affordable Care Act
TRI-LINYAH 2 ACA Affordable Care Act
TRI-LO-ESTARYLLA 2 ACA Affordable Care Act
PAGE 82 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
TRI-LO-MARZIA 2 ACA Affordable Care Act
TRI-LO-MILI 2 ACA Affordable Care Act
TRI-LO-SPRINTEC 2 ACA Affordable Care Act
TRI-MILI 2 ACA Affordable Care Act
TRI-PREVIFEM 2 ACA Affordable Care Act
TRI-SPRINTEC 2 ACA Affordable Care Act
TRI-VYLIBRA 2 ACA Affordable Care Act
TRI-VYLIBRA LO 2 ACA Affordable Care Act
TRIVORA-28 2 ACA Affordable Care Act
TULANA 2 ACA Affordable Care Act
TYBLUME 2 ACA Affordable Care Act
VELIVET 2 ACA Affordable Care Act
VESTURA 2
VIENVA 2 ACA Affordable Care Act
VIORELE 2 ACA Affordable Care Act
VOLNEA 2 ACA Affordable Care Act
VYFEMLA 2 ACA Affordable Care Act
VYLIBRA 2 ACA Affordable Care Act
WERA 2 ACA Affordable Care Act
XULANE 2 ACA Affordable Care Act
ZARAH 2 ACA Affordable Care Act
ZOVIA 1-35 2 ACA Affordable Care Act
ZOVIA 1-35E 2 ACA Affordable Care Act
ZUMANDIMINE 2 ACA Affordable Care Act
PAGE 83 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PITUITARY
desmopressin acetate (0.01% solution, 10 mcg/0.1 ml spr) 2 PA
desmopressin acetate (0.1 mg tb, 0.2 mg tb) 2 AL1 At least 8 yrs old
STIMATE 3 PA
PROGESTINS
hydroxyprogest 250 mg/ml vial 5QL 2 ML / 1 FILL
S
MAKENA 250 MG/ML VIAL 5QL 2 ML / 1 FILL
S
MAKENA 275 MG/1.1 ML AUTOINJCT 5QL 2.2 ML / 1 FILL
S
medroxyprogesterone acetate (2.5 mg tab, 5 mg tab, 10mg tab)
1
megestrol acetate (20 mg tablet, 40 mg tablet, acet 40mg/ml susp)
2
norethindrone ac (lupaneta) 2
norethindrone acetate 2
progesterone (100 mg capsule, 200 mg capsule) 2
HYPOTENSIVE AGENTSCENTRAL ALPHA-AGONISTS
clonidine 2
clonidine hcl (0.1 mg tablet, 0.2 mg tablet, 0.3 mg tablet) 1
guanfacine hcl 1
methyldopa 2
DIRECT VASODILATORShydralazine hcl (10 mg tablet, 25 mg tablet, 50 mg tablet,100 mg tablet)
2
minoxidil 2
PAGE 84 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
INSULINSINTERMEDIATE-ACTING INSULINS
HUMULIN 70-30 3
HUMULIN 70/30 KWIKPEN 3
HUMULIN N 3
HUMULIN N KWIKPEN 3
relion novolin 70-30 flexpen 3
relion novolin 70-30 vial 3
relion novolin n 100 unit/ml 3
relion novolin n u-100 flexpen 3
LONG-ACTING INSULINSLANTUS 3
LANTUS SOLOSTAR 3
LEVEMIR 3 PA
LEVEMIR FLEXTOUCH 3 PA
SOLIQUA 100-33 3
TOUJEO MAX SOLOSTAR 3
TOUJEO SOLOSTAR 3
XULTOPHY 100-3.6 3
RAPID-ACTING INSULINSHUMALOG 3
HUMALOG JUNIOR KWIKPEN 3
HUMALOG KWIKPEN U-100 3
HUMALOG KWIKPEN U-200 3
HUMALOG MIX 50-50 3
HUMALOG MIX 50-50 KWIKPEN 3
HUMALOG MIX 75-25 3
HUMALOG MIX 75-25 KWIKPEN 3
PAGE 85 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
insulin lispro 2
insulin lispro junior kwikpen 2
insulin lispro kwikpen u-100 2
insulin lispro protamine mix 2
SHORT-ACTING INSULINSHUMULIN R 3
HUMULIN R U-500 3
HUMULIN R U-500 KWIKPEN 3
relion novolin r 100 unit/ml 3
relion novolin r u-100 flexpen 3
ION-REMOVING AGENTSPHOSPHATE-REMOVING AGENTS
calcium acetate (667 mg capsule, 667 mg gelcap) 2
PHOSLYRA 3
sevelamer carbonate 2
POTASSIUM-REMOVING AGENTSsodium polystyrene sulfonate (sod polystyren 15 g/60 ml,sodium polystyrene powder)
2
MACROLIDE ANTIBIOTICSOTHER MACROLIDE ANTIBIOTICS
azithromycin (100 mg/5 ml susp, 200 mg/5 ml susp) 2
azithromycin (250 mg tablet, 500 mg tablet, 600 mgtablet)
1
clarithromycin (125 mg/5 ml sus, 250 mg/5 ml sus) 2 AL1 Up to 12 yrs old
clarithromycin (250 mg tablet, 500 mg tablet) 2
DIFICID (40 MG/ML SUSPENSION, 200 MG TABLET) 3 PA
MISC. BETA-LACTAM ANTIBIOTICSMONOBACTAM ANTIBIOTICS
CAYSTON 5PA
S
PAGE 86 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MISCELLANEOUS THERAPEUTIC AGENTS5-ALPHA-REDUCTASE INHIBITORS
dutasteride 2
finasteride 5 mg tablet 1
ALCOHOL DETERRENTSdisulfiram 2
ANTIDOTESleucovorin calcium (5 mg tab, 10 mg tab, 15 mg tab, 25mg tab)
2
VISTOGARD 5PA
S
ANTIGOUT AGENTSallopurinol 1
colchicine 2
febuxostat 2 ST
BONE RESORPTION INHIBITORS
alendronate sod 70 mg/75 ml 2 PA
alendronate sodium (5 mg tablet, 10 mg tab, 35 mg tab,70 mg tab)
1
alendronate sodium 40 mg tab 2
etidronate disodium 2
ibandronate sodium 150 mg tab 2
CARIOSTATIC AGENTSdenta 5000 plus 1
dentagel 1
fluoride 1AL1 Up to 5 yrs old
ACA Affordable Care Act
fluoritab (0.5 mg tablet chew, 1 mg tablet chew) 1AL1 Up to 5 yrs old
ACA Affordable Care Act
flura-drops 1AL1 Up to 5 yrs old
ACA Affordable Care Act
PAGE 87 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ludent fluoride 1AL1 Up to 5 yrs old
ACA Affordable Care Act
sf 1
sf 5000 plus 1
sodium fluoride (0.25 (0.55) mg, 0.5 mg(1.1 mg), 0.5mg/ml drop, 1 mg (2.2 mg))
1AL1 Up to 5 yrs old
ACA Affordable Care Act
COMPLEMENT INHIBITORS
BERINERT 5PA
S
CINRYZE 5PA
S
FIRAZYR 5
QL 9 ML / 1 FILL
PA
S
HAEGARDA 5PA
S
KALBITOR 5PA
S
ORLADEYO 5
QL 1 CAP / 1 DAY
PA
S
RUCONEST 5PA
S
TAKHZYRO 5
QL 4 ML / 28 DAYS
PA
S
DISEASE-MODIFYING ANTIRHEUMATIC AGENTS
ACTEMRA 162 MG/0.9 ML SYRINGE 5
QL 4 SYRINGES / 28DAYS
PA
S
PAGE 88 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
ACTEMRA ACTPEN 5PA
S
CIMZIA (MG/ML SYRINGE KIT, MG/ML(X3)START KT) 5
QL 2 SYRINGES / 28DAYS
PA
S
ENBREL (25 MG/0.5 ML SYRINGE, 25 MG/0.5 ML VIAL) 5
QL 4 ML (8 DOSES) / 28DAYS
PA
S
ENBREL 25 MG KIT 5
QL 8 VIALS (8 ML) / 28DAYS
PA
S
ENBREL 50 MG/ML SYRINGE 5
QL 4 ML (4 DOSES) / 28DAYS
PA
S
ENBREL MINI 5
QL 4 ML (4 DOSES) / 28DAYS
PA
S
ENBREL SURECLICK 5
QL 4 ML (4 DOSES) / 28DAYS
PA
S
HUMIRA 5
QL 2 SYRINGES / 28DAYS
PA
S
HUMIRA PEN 5
QL 2 PENS / 28 DAYS
PA
S
PAGE 89 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
HUMIRA PEN CROHN'S-UC-HS 5
QL 2 PENS / 28 DAYS
PA
S
HUMIRA PEN PSOR-UVEITS-ADOL HS 5
QL 2 PENS / 28 DAYS
PA
S
HUMIRA(CF) 5
QL 2 SYRINGES / 28DAYS
PA
S
HUMIRA(CF) PEDI CROHN 80MG/0.8 5
QL 3 PENS / 28 DAYS
PA
S
HUMIRA(CF) PEN 40 MG/0.4 ML 5
QL 2 PENS / 28 DAYS
PA
S
HUMIRA(CF) PEN 80 MG/0.8 ML 5
QL 3 PENS / 28 DAYS
PA
S
HUMIRA(CF) PEN CROHN'S-UC-HS 5
QL 3 PENS / 28 DAYS
PA
S
HUMIRA(CF) PEN PEDIATRIC UC 5
QL 3 PENS / 28 DAYS
PA
S
HUMIRA(CF) PEN PSOR-UV-ADOL HS 5
QL 2 PENS / 28 DAYS
PA
S
KINERET 5
QL 28 SYRINGES / 28DAYS
PA
S
PAGE 90 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
leflunomide 2
OLUMIANT 5
QL 1 TAB / 1 DAY
PA
S
ORENCIA (50 MG/0.4 ML SYRINGE, 87.5 MG/0.7 MLSYRINGE, 125 MG/ML SYRINGE)
5
QL 4 SYRINGES / 28DAYS
PA
S
ORENCIA CLICKJECT 5
QL 4 ML / 28 DAYS
PA
S
OTEZLA 28 DAY STARTER PACK 5
QL 55 TABS / 28 DAYS
PA
S
OTEZLA 30 MG TABLET 5
QL 2 TABS / 1 DAY
PA
S
OTEZLA STARTER PACK 5
QL 2 PACKS / 28 DAYS
PA
S
RINVOQ 5
QL 1 TAB / 1 DAY
PA
S
IMMUNOMODULATORY AGENTS
AUBAGIO 5QL 1 TAB / 1 DAY
S
AVONEX (30 MCG VIAL KIT, PREFILLED SYR 30 MCG KT) 5QL 1 KIT / 28 DAYS
S
AVONEX 30 MCG/0.5 ML SYRINGE 5QL 4 SYRINGES / 28
DAYSS
PAGE 91 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AVONEX PEN 5QL 1 KIT / 28 DAYS
S
BAFIERTAM 5QL 4 CAPS / 1 DAY
S
BETASERON 0.3 MG KIT 5QL 15 ML / 28 DAYS
S
BETASERON 0.3 MG VIAL 5QL 15 ML / 30 DAYS
S
dimethyl fumarate 5QL 2 CAPS / 1 DAY
S
ENSPRYNG 5PA
S
GILENYA 5QL 1 CAP / 1 DAY
S
glatiramer 20 mg/ml syringe 5QL 30 ML / 30 DAYS
S
glatiramer 40 mg/ml syringe 5QL 12 ML / 28 DAYS
S
GLATOPA 20 MG/ML SYRINGE 5QL 30 ML / 30 DAYS
S
GLATOPA 40 MG/ML SYRINGE 5QL 12 ML / 28 DAYS
S
KESIMPTA PEN 5QL 1 PEN / 28 DAYS
S
MAYZENT 0.25 MG STARTER PACK 5QL 12 TABS / 4 DAYS
S
MAYZENT 0.25 MG TABLET 5QL 4 TABS / 1 DAY
S
PAGE 92 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
MAYZENT 2 MG TABLET 5QL 1 TAB / 1 DAY
S
PLEGRIDY 5QL 1 ML / 28 DAYS
S
PLEGRIDY PEN 5QL 1 ML / 28 DAYS
S
REBIF (22 MCG/0.5 ML SYRINGE, 44 MCG/0.5 MLSYRINGE)
5QL 6 ML / 28 DAYS
S
REBIF REBIDOSE (22 MCG/0.5 ML, 44 MCG/0.5 ML) 5QL 6 ML / 28 DAYS
S
REBIF REBIDOSE TITRATION PACK 5QL 4.2 ML / 28 DAYS
S
REBIF TITRATION PACK 5QL 4.2 ML / 28 DAYS
S
REDITREX 3 PA
THALOMID 3S
ONC Oncology
VUMERITY 5QL 4 CAPS / 1 DAY
S
ZEPOSIA 0.23-0.46 MG START PCK 5QL 7 CAPS / 180 DAYS
S
ZEPOSIA 0.23-0.46-0.92 MG KIT 5QL 37 CAPS / 180 DAYS
S
ZEPOSIA 0.92 MG CAPSULE 5QL 1 CAP / 1 DAY
S
IMMUNOSUPPRESSIVE AGENTSazathioprine 2
cyclosporine (25 mg capsule, 100 mg capsule) 2
PAGE 93 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
cyclosporine modified (25 mg, 50 mg, 100 mg, 100mg/ml) 2
GENGRAF (25 MG CAPSULE, 100 MG CAPSULE, 100MG/ML SOLUTION)
2
MAVENCLAD 5PA
S
mycophenolate mofetil (200 mg/ml susp, 250 mg capsule,500 mg tablet)
2
mycophenolic acid 2
sirolimus (0.5 mg tablet, 1 mg tablet, 1 mg/ml solution, 2mg tablet)
2
tacrolimus (0.5 mg capsule, 1 mg capsule, 5 mg capsule) 2
OTHER MISCELLANEOUS THERAPEUTIC AGENTS
ARCALYST 5PA
S
CERDELGA 5PA
S
CYSTAGON 3
dalfampridine er 5
QL 2 TABS / 1 DAY
PA
S
EVRYSDI 5PA
S
GALAFOLD 5
QL 14 CAPS / 28 DAYS
PA
S
ILARIS 5
QL 2 ML / 28 DAYS
PA
S
ISTURISA 5PA
S
PAGE 94 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
levocarnitine 1 g/10 ml soln 2
levocarnitine sf 2
miglustat 5PA
S
REZUROCK 3
QL 1 TAB / 1 DAY
PA
S
ONC Oncology
RUZURGI 5
QL 10 TABS / 1 DAY
PA
S
sapropterin dihydrochloride 5PA
S
THIOLA 5PA
S
THIOLA EC 5PA
S
tiopronin 5PA
S
TYBOST 3
ZOKINVY 5PA
S
PROTECTIVE AGENTSELMIRON 3
NONHORMONAL CONTRACEPTIVES
TODAY CONTRACEPTIVE SPONGE 3 ACA Affordable Care Act
vcf 1 ACA Affordable Care Act
PAGE 95 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
NONSTEROIDAL ANTI-INFLAMMATORY AGENTSCYCLOOXYGENASE-2 (COX-2) INHIBITORS
celecoxib 2
OTHER NONSTEROIDAL ANTI-INFLAM. AGENTSdiclofenac potassium 2
diclofenac sodium (sod dr 25 mg tab, sod dr 50 mg tab,sod dr 75 mg tab, sod ec 25 mg tab, sod ec 50 mg tab, sodec 75 mg tab, sodium 1% gel)
2
diclofenac sodium er 2
etodolac (200 mg capsule, 300 mg capsule) 1
etodolac (400 mg tablet, 500 mg tablet) 2
etodolac er 2
flurbiprofen 2
ibuprofen (400 mg tablet, 600 mg tablet, 800 mg tablet) 1
indomethacin (25 mg capsule, 50 mg capsule) 1 AQ1 Up to 64 yrs old; 20 /1 FILL
ketorolac 10 mg tablet 2 QL 20 TABS / RX
meloxicam (7.5 mg tablet, 15 mg tablet) 1
nabumetone 2
naproxen (250 mg tablet, 375 mg tablet, 500 mg kit, 500mg tablet)
1
naproxen (dr 375 mg tablet, dr 500 mg tablet) 2
piroxicam 1
sulindac 2
tolmetin sodium 2 PA
SALICYLATES
butalbital-asa-caffeine cap 1 QL 6 CAPS / 1 DAY
salsalate 2
OXYTOCICSmethylergonovine 0.2 mg tablet 2
PAGE 96 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PARATHYROID AND ANTIPARATHYROID AGENTSANTIPARATHYROID AGENTS
calcitonin-salmon 200 units sp 2
cinacalcet hcl 2
SENSIPAR 3
PARATHYROID AGENTS
FORTEO 5PA
S
teriparatide 5PA
S
TYMLOS 5PA
S
PENICILLIN ANTIBIOTICSAMINOPENICILLIN ANTIBIOTICS
amoxicillin (125 mg tab chew, 125 mg/5 ml susp, 200mg/5 ml susp, 250 mg capsule, 250 mg tab chew, 250mg/5 ml susp, 400 mg/5 ml susp, 500 mg capsule, 500 mgtablet, 875 mg tablet)
1
amoxicillin-clavulanate potass (200-28.5 mg tab chew,200-28.5 mg/5 ml sus, 250-125 mg tablet, 250-62.5 mg/5ml sus, 400-57 mg tab chew, 400-57 mg/5 ml susp, 500-125 mg tablet, 600-42.9 mg/5 ml sus, 875-125 mg tablet)
2
ampicillin trihydrate 1
NATURAL PENICILLIN ANTIBIOTICSpenicillin v potassium (125 mg/5 ml soln, 250 mg/5 mlsoln)
2
penicillin v potassium (250 mg tablet, 500 mg tablet) 1
PENICILLINASE-RESISTANT PENICILLINSdicloxacillin sodium 2
PHARMACEUTICAL AIDS
SHINGRIX ADJUVANT COMPONENT 3 QL 1 KIT / RX
VAXCHORA BUFFER COMPONENT 3
PAGE 97 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
RENIN-ANGIOTENSIN-ALDOSTERONE SYS. INHIBANGIOTENSIN II RECEPTOR ANTAGONISTS
candesartan cilexetil 2
ENTRESTO 3
irbesartan 1
irbesartan-hydrochlorothiazide 2
losartan potassium 1
losartan-hydrochlorothiazide 1
olmesartan medoxomil 2
olmesartan-hydrochlorothiazide 2
telmisartan 2
telmisartan-hydrochlorothiazid 2
valsartan 2
valsartan-hydrochlorothiazide 2
ANGIOTENSIN-CONVERTING ENZYME INHIBITORSbenazepril hcl 1
benazepril-hydrochlorothiazide 2
captopril 2
captopril-hydrochlorothiazide 2
enalapril maleate (2.5 mg tab, 5 mg tablet, 10 mg tab, 20mg tab)
2
enalapril-hydrochlorothiazide 1
fosinopril sodium 1
fosinopril-hydrochlorothiazide 2
lisinopril 1
lisinopril-hydrochlorothiazide 1
moexipril hcl 2
perindopril erbumine 2
quinapril hcl 1
PAGE 98 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
quinapril-hydrochlorothiazide 2
ramipril 1
trandolapril 2
MINERALOCORTICOID (ALDOSTERONE) ANTAGNTSeplerenone 2
spironolactone 2
spironolactone-hctz 2
RESPIRATORY TRACT AGENTSANTIFIBROTIC AGENTS
ESBRIET 5PA
S
OFEV 5PA
S
ANTITUSSIVESbenzonatate (100 mg capsule, perle 100 mg cap, 200 mgcapsule)
2
codeine-guaifenesin 2
QL 60 ML / 1 DAY
AL1 At least 18 yrs old
AQ1 At least 18 yrs old;60 / 1 day(s)
guaifenesin-codeine 2 AQ1 At least 18 yrs old;60 / 1 day(s)
promethazine-dm 1
MUCOLYTIC AGENTSacetylcysteine (10% vial, 20% vial) 2
PULMOZYME 5
QL 150 ML / 30 DAYS
PA
S
PHOSPHODIESTERASE TYPE 4 INHIBITORS
DALIRESP 3 PA
PAGE 99 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VASODILATING AGENTS (RESPIRATORY TRACT)
ADEMPAS 5PA
S
ambrisentan 5PA
S
bosentan 5PA
S
epoprostenol sodium 5PA
S
FLOLAN 1.5 MG VIAL 5PA
S
OPSUMIT 5PA
S
TRACLEER 32 MG TABLET FOR SUSP 5PA
S
treprostinil 5PA
S
TYVASO 5PA
S
TYVASO REFILL KIT 5PA
S
TYVASO STARTER KIT 5PA
S
UPTRAVI (200 MCG TABLET, 200-800 TITRATION PACK,400 MCG TABLET, 600 MCG TABLET, 800 MCG TABLET,1,000 MCG TABLET, 1,200 MCG TABLET, 1,400 MCGTABLET, 1,600 MCG TABLET)
5PA
S
VENTAVIS 5PA
S
PAGE 100 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SKELETAL MUSCLE RELAXANTSCENTRALLY ACTING SKELETAL MUSCLE RELAXNT
chlorzoxazone 500 mg tablet 2
cyclobenzaprine hcl (5 mg tablet, 10 mg tablet) 2
methocarbamol (500 mg tablet, 750 mg tablet) 2
tizanidine hcl (2 mg tablet, 4 mg tablet) 2
DIRECT-ACTING SKELETAL MUSCLE RELAXANTSdantrolene sodium (25 mg cap, 50 mg cap, 100 mg cap) 2
GABA-DERIVATIVE SKELETAL MUSCLE RELAXANTbaclofen (5 mg tablet, 10 mg tablet, 20 mg tablet) 2
SKIN AND MUCOUS MEMBRANE AGENTSANTIPRURITICS AND LOCAL ANESTHETICS
lidocaine-prilocaine 2 QL 60 GM / 1 FILL
phenazopyridine hcl 1
ASTRINGENTSDRYSOL 3
CELL STIMULANTS AND PROLIFERANTSAVITA 2
tretinoin (0.01% gel, 0.025% cream, 0.025% gel, 0.05%cream, 0.1% cream)
2
KERATOLYTIC AGENTS
sod sulfacet-sulfur 10-5% clsr 2 QL 12 ML / 1 DAY
sodium sulfacetamide-sulfur (10-5% crm, sod lotn) 2
sss 10-5 cream 2
urea (cream, lotion) 2
SKIN AND MUCOUS MEMBRANE AGENTS, MISC.acitretin 2
adapalene (0.1% cream, 0.3% gel, 0.3% gel pump) 2 PA
adapalene 0.1% gel 2
PAGE 101 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
AMNESTEEM 2
azelaic acid 2
calcipotriene (cream, ointment, solution) 2 QL 120 GM / 30 DAYS
CLARAVIS 2
COSENTYX (2 SYRINGES) 5PA
S
COSENTYX PEN 5PA
S
COSENTYX PEN (2 PENS) 5PA
S
COSENTYX SYRINGE 5PA
S
DIFFERIN 0.1% GEL 3
DUPIXENT 300 MG/2 ML PEN 5
QL 2 PENS / 28 DAYS
PA
S
DUPIXENT 300 MG/2 ML SYRINGE 5
QL 4 ML / 28 DAYS
PA
S
imiquimod 5% cream packet 2
isotretinoin (10 mg capsule, 20 mg capsule, 30 mgcapsule, 40 mg capsule)
2
MYORISAN 2
pimecrolimus 2
podofilox 2
SKYRIZI 5PA
S
SKYRIZI (2 SYRINGES) KIT 5PA
S
PAGE 102 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SKYRIZI PEN 5PA
S
tacrolimus (0.03% ointment, 0.1% ointment) 2
tazarotene 0.1% cream 2 QL 30 GM / 30 DAYS
ZENATANE 2
SMOOTH MUSCLE RELAXANTSRESPIRATORY SMOOTH MUSCLE RELAXANTS
theophylline (er 400 mg tablet, er 600 mg tablet) 2
theophylline anhydrous 2
SOMATOSTATIN AGONISTS AND ANTAGONISTSSOMATOSTATIN AGONISTS
BYNFEZIA 5PA
S
octreotide acetate (0.05 mg/ml vl, 50 mcg/ml amp, 50mcg/ml vial)
5QL 3 ML / 1 DAY
S
octreotide acetate (1,000 mcg/ml vial, 5,000 mcg/5 mlvial)
5QL 9 VIALS / 30 DAYS
S
octreotide acetate (100 mcg/ml amp, 100 mcg/ml vl) 5QL 5 ML / 1 DAY
S
octreotide acetate (50 mcg/ml syr, 100 mcg/ml syr, 500mcg/ml syr)
5 S
octreotide acetate (500 mcg/ml amp, 500 mcg/ml vl) 5QL 7 ML / DAY
S
octreotide acetate (acet 200 mcg/ml vl, 1,000 mcg/5 mlvial)
5QL 7.5 ML / 1 DAY
S
SANDOSTATIN LAR DEPOT (10 MG KT, 10 MG VL) 5QL 1 KIT / 28 DAYS
S
SANDOSTATIN LAR DEPOT (20 MG KT, 20 MG VL) 5QL 2 KITS / 28 DAYS
S
PAGE 103 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
SANDOSTATIN LAR DEPOT (30 MG KT, 30 MG VL) 5QL 3 KITS / 28 DAYS
S
SIGNIFOR 5PA
S
SYMPATHOMIMETIC (ADRENERGIC) AGENTSALPHA- AND BETA-ADRENERGIC AGONISTS
epinephrine 0.15 mg auto-injct (teva) 2
epinephrine 0.15 mg auto-inject (generic for epi-pen jr /mylan)
2
epinephrine 0.3 mg auto-inject (generic for adrenaclick) 2
epinephrine 0.3 mg auto-inject (generic for epi-pen /mylan)
2
epinephrine 0.3 mg auto-inject (teva) 2
SYMJEPI 3
ALPHA-ADRENERGIC AGONISTSmidodrine hcl 2
TETRACYCLINE ANTIBIOTICSAMINOMETHYLCYCLINES
NUZYRA (150 MG TABLET, 150 MG TABLET-7 DAY, 150MG-7 DAY WITH LOAD)
3 PA
THYROID AND ANTITHYROID AGENTSANTITHYROID AGENTS
methimazole 1
propylthiouracil 2
THYROID AGENTSeuthyrox 2
levothyroxine sodium (25 mcg tablet, 50 mcg tablet, 75mcg tablet, 88 mcg tablet, 100 mcg tablet, 112 mcgtablet, 125 mcg tablet, 137 mcg tablet, 150 mcg tablet,175 mcg tablet, 200 mcg tablet, 300 mcg tablet)
2
liothyronine sodium (5 mcg tab, 25 mcg tab, 50 mcg tab) 2
SYNTHROID 3
PAGE 104 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
VASODILATING AGENTSNITRATES AND NITRITES
isosorbide dinitrate (5 mg tab, 10 mg tab, 20 mg tab, 30mg tab)
2
isosorbide mononitrate 2
isosorbide mononitrate er 2
NITRO-BID 3
nitroglycerin (0.3 mg tablet, 0.4 mg tablet, 0.6 mg tablet) 2
nitroglycerin patch 2
PHOSPHODIESTERASE TYPE 5 INHIBITORS
sildenafil 20 mg tablet (generic for revatio) 2 QL 1 TAB / 1 DAY
tadalafil (2.5 mg tablet, 5 mg tablet) 2QL 1 TAB / 1 DAY
PA
tadalafil 20 mg tablet (generic for adcirca) 2QL 2 TABS / 1 DAY
PA
VASODILATING AGENTS, MISCELLANEOUSaspirin-dipyridamole er 2
dipyridamole 2
VERQUVO 3 PA
VITAMINSMULTIVITAMIN PREPARATIONS
completenate 2
m-natal plus 1
mynatal plus 1
mynatal-z 1
O-CAL PRENATAL 1
pnv 29-1 2
PRENATA 3
PRENATABS FA 1
PAGE 105 LAST UPDATED 10/2021
PRODUCT DESCRIPTION TIER LIMITS & RESTRICTIONS
PRENATABS RX 2
prenatal plus (iron tablet, pnv multivit tab) 1
prenatal vitamin plus low iron 1
prenatal-u 2 PA
PRENATE ELITE 3 PA
preplus 1
PUREFE OB PLUS 1
se-natal 19 1
TRINATE 2
VINATE CARE 1
vinate one 1
vinate-m 1
VITAMIN B COMPLEXcyanocobalamin injection 1
folic acid 1 mg tablet 1
VITAMIN Dcalcitriol (0.25 mcg capsule, 0.5 mcg capsule, 1 mcg/mlsolution)
2
vitamin d2 1.25mg(50,000 unit) 1
VITAMIN K ACTIVITY
phytonadione 5 mg tablet 2 QL 3 TABS / 1 FILL
PAGE 106 LAST UPDATED 10/2021
Index of Covered Drugs
Aabacavir 49abacavir-lamivudine 49abacavir-lamivudine-zidovudine 50abiraterone acetate 31acamprosate calcium 65acarbose 20acebutolol hcl 64acetaminophen-codeine 1acetazolamide 24acetazolamide er 24acetic acid 7acetylcysteine 99acitretin 101ACTEMRA 88ACTEMRA ACTPEN 89ACTHAR 68ACTHIB 52acyclovir 57ADACEL TDAP 52adapalene 101ADDERALL XR 4adefovir dipivoxil 57ADEMPAS 100adenovirus type 4 52adenovirus type 4 and type 7 52adenovirus type 7 52ADVAIR DISKUS 67ADVAIR HFA 67ADVATE 24ADYNOVATE 24AFINITOR 31AFINITOR DISPERZ 31AFIRMELLE 77AFLURIA QUAD 2019-20 (3YR UP) 52AFLURIA QUAD 2019-20 (6-35MO) 52AFLURIA QUAD 2019-2020 52AFLURIA QUAD 2020-2021 52AFLURIA QUAD 2020-21 (3YR UP) 52AFLURIA QUAD 2020-21 (6-35MO) 52
AFLURIA QUAD 2021-2022 52AFLURIA QUAD 2021-22 (3YR UP) 52AFLURIA QUAD 2021-22 (6-35MO) 52AFSTYLA 25AJOVY AUTOINJECTOR 29AJOVY SYRINGE 29albendazole 6albuterol sulfate 61alclometasone dipropionate 10ALECENSA 31alendronate sodium 87ALFERON N 56alfuzosin hcl er 1ALINIA 46ALLI 73allopurinol 87alogliptin 20alogliptin-metformin 20alogliptin-pioglitazone 20alosetron hcl 72ALPHANATE 25ALPHANINE SD 25alprazolam 58alprazolam er 58alprazolam xr 58ALPROLIX 25ALTAVERA 77ALYACEN 77AMABELZ 70amantadine 46ambrisentan 100AMETHIA 77AMETHIA LO 77amiloride hcl 68amiloride-hydrochlorothiazide 68amiodarone hcl 11amitriptyline hcl 19amlodipine besylate 63amlodipine besylate-benazepril 63amlodipine-olmesartan 63amlodipine-valsartan 63
amlodipine-valsartan-hctz 63ammonium lactate 70AMNESTEEM 102amoxicillin 97amoxicillin-clavulanate potass 97ampicillin trihydrate 97anagrelide hcl 51anastrozole 32ANORO ELLIPTA 13anucort-hc 10aprepitant 22APRI 77APTIOM 15APTIVUS 50ARANELLE 77ARANESP 61ARCALYST 94aripiprazole 47aripiprazole odt 47armodafinil 6ARNUITY ELLIPTA 67asenapine maleate 47ASHLYNA 77ASMANEX 67ASMANEX HFA 67aspirin-dipyridamole er 105ASTRAZENECA COVID19 VAC(UNAPP) 52atazanavir sulfate 50atenolol 64atenolol-chlorthalidone 64atomoxetine hcl 65atorvastatin calcium 28atovaquone 47atovaquone-proguanil hcl 46atropine sulfate 71ATROVENT HFA 13AUBAGIO 91AUBRA 77AUBRA EQ 78AUROVELA 78AUROVELA 24 FE 78
AUROVELA FE 78AUSTEDO 66AVIANE 78AVITA 101AVONEX 91AVONEX PEN 92AYUNA 78AYVAKIT 32azathioprine 93azelaic acid 102azelastine hcl 71azithromycin 86AZURETTE 78
Bbacitracin 6bacitracin-polymyxin 6baclofen 101BAFIERTAM 92balsalazide disodium 72BALVERSA 32BALZIVA 78BANZEL 15BAQSIMI 27BARACLUDE 57BEKYREE 78benazepril hcl 98benazepril-hydrochlorothiazide 98BENEFIX 25benznidazole 47benzonatate 99benztropine mesylate 46BERINERT 88BESIVANCE 6betamethasone diprop augmented 10betamethasone dipropionate 10betamethasone valerate 10BETASERON 92betaxolol hcl 24,64bethanechol chloride 60BEXSERO 52
bicalutamide 32BIKTARVY 50bimatoprost 24bisoprolol fumarate 64bisoprolol-hydrochlorothiazide 64BLEPHAMIDE S.O.P. 6BLISOVI 24 FE 78BLISOVI FE 78BOOSTRIX TDAP 52bosentan 100BOSULIF 32BRAFTOVI 32BREO ELLIPTA 67BRIELLYN 78BRILINTA 51brimonidine tartrate 23BRIVIACT 15bromfenac sodium 9bromocriptine mesylate 68BRUKINSA 32budesonide 67budesonide ec 76budesonide-formoterol fumarate 67bumetanide 68buprenorphine 3buprenorphine-naloxone 3bupropion hcl 18bupropion hcl sr 18bupropion xl 18buspirone hcl 57butalbital-acetaminophen 1butalbital-acetaminophen-caffe 1butalbital-aspirin-caffeine 96BYDUREON BCISE 20BYDUREON PEN 20BYETTA 20BYNFEZIA 103
Ccabergoline 68CABLIVI 51
CABOMETYX 32calcipotriene 102calcitonin-salmon 97calcitriol 106calcium acetate 86CAMILA 78CAMRESE 78CAMRESE LO 78candesartan cilexetil 98capecitabine 33CAPLYTA 47CAPRELSA 33captopril 98captopril-hydrochlorothiazide 98CARBAGLU 69carbamazepine 15carbamazepine er 15carbidopa-levodopa 46carbidopa-levodopa er 46carbidopa-levodopa-entacapone 46carteolol hcl 24CARTIA XT 62carvedilol 64CAYSTON 86CAZIANT 78cefadroxil 66cefdinir 66cefixime 66cefpodoxime proxetil 66cefprozil 66cefuroxime 66celecoxib 96cephalexin 66CERDELGA 94cevimeline hcl 60CHANTIX 59CHATEAL 78CHATEAL EQ 78CHEMET 75chlordiazepoxide hcl 58chlorhexidine gluconate 7
chloroquine phosphate 46chlorpromazine hcl 48chlorthalidone 68chlorzoxazone 101CHOLBAM 73cholestyramine 28cholestyramine light 28ciclopirox 23cilostazol 51CILOXAN 6cimetidine 56CIMZIA 89cinacalcet hcl 97CINRYZE 88CIPRO 12CIPRO HC 6ciprofloxacin 12ciprofloxacin hcl 6,12ciprofloxacin-dexamethasone 7citalopram hbr 19CLARAVIS 102clarithromycin 86CLEOCIN 7clindamycin (pediatric) 13clindamycin hcl 13clindamycin ph 1% gel (generic for cleocin t) 8clindamycin phos-benzoyl perox 7clindamycin phosphate 8clindamycin-benzoyl peroxide 8clobazam 17,18clobetasol emollient 10clobetasol propionate 10clomipramine hcl 19clonazepam 18clonidine 84clonidine hcl 84clopidogrel 51clotrimazole 23clotrimazole-betamethasone 23clozapine 47clozapine odt 47
COAGADEX 25codeine sulfate 1codeine-guaifenesin 99colchicine 87colestipol hcl 28COMBIVENT RESPIMAT 13COMETRIQ 33COMIRNATY 52COMPLERA 50completenate 105CONCERTA 5COPIKTRA 33CORIFACT 25CORLANOR 63COSENTYX (2 SYRINGES) 102COSENTYX PEN 102COSENTYX PEN (2 PENS) 102COSENTYX SYRINGE 102COTELLIC 33CREON 73CRESEMBA 22cromolyn sodium 10CRYSELLE 78CUVPOSA 13cyanocobalamin injection 106CYCLAFEM 78cyclobenzaprine hcl 101cyclopentolate hcl 71CYCLOPHOSPHAMIDE 34cycloserine 30CYCLOSET 68cyclosporine 93cyclosporine modified 94cyproheptadine hcl 72CYRED 78CYRED EQ 78CYSTADROPS 71CYSTAGON 94CYSTARAN 71
DD-PENAMINE 75dalfampridine er 94DALIRESP 99danazol 77dantrolene sodium 101dapsone 30DAPTACEL DTAP 52DASETTA 78DAURISMO 34DAYSEE 78DEBLITANE 79deferasirox 75deferiprone 75demeclocycline hcl 12denta 5000 plus 87dentagel 87dermazene 8DESCOVY 50desipramine hcl 19desmopressin acetate 84desogestr-eth estrad eth estra 79desogestrel-ethinyl estradiol 79desonide 10desoximetasone 10desvenlafaxine suc er 100 mg tablet (generic forpristiq) 18desvenlafaxine suc er 25 mg tablet (generic forpristiq) 18desvenlafaxine suc er 50 mg tablet (generic forpristiq) 18dexamethasone 76DEXAMETHASONE INTENSOL 76dexamethasone sodium phosphate 9,76dexmethylphenidate hcl 5dexmethylphenidate hcl er 5dextroamp-amphetamin 15 mg tab (genericadderall) 4dextroamp-amphetamin 20 mg tab (genericadderall) 4
dextroamphetamine sulfate 4dextroamphetamine sulfate er 4dextroamphetamine-amphetamine 4DIACOMIT 15,16diazepam 58,59diclofenac potassium 96diclofenac sodium 9,96diclofenac sodium er 96dicloxacillin sodium 97dicyclomine hcl 13DIFFERIN 102DIFICID 86DIGITEK 63DIGOX 63digoxin 63DILANTIN 18DILT-XR 62diltiazem 24hr er 62diltiazem 24hr er (cd) 62diltiazem 24hr er (xr) 62diltiazem hcl 62dimethyl fumarate 92diphenoxylate-atropine 72diphtheria-tetanus toxoids-ped 52dipyridamole 105disopyramide phosphate 11disulfiram 87divalproex sodium 16divalproex sodium er 16dofetilide 12DOJOLVI 69donepezil hcl 60donepezil hcl odt 60dorzolamide hcl 24dorzolamide-timolol 24DOTTI 70doxazosin mesylate 64doxepin hcl 19doxycycline hyclate 7,12doxycycline monohydrate 12dronabinol 22
drospirenone-ethinyl estradiol 79DRYSOL 101DULERA 67duloxetine hcl 18DUPIXENT PEN 9,102DUPIXENT SYRINGE 9,102dutasteride 87
Eeconazole nitrate 23ed-spaz 14EDURANT 49efavirenz 49efavirenz-emtric-tenofov disop 50eletriptan hbr 30ELINEST 79ELIQUIS 14ELLA 79ELMIRON 95ELOCTATE 25ELURYNG 79EMCYT 34EMEND 22EMGALITY PEN 29EMGALITY SYRINGE 29EMOQUETTE 79emtricitabine 50emtricitabine-tenofovir disop 50enalapril maleate 98enalapril-hydrochlorothiazide 98ENBREL 89ENBREL MINI 89ENBREL SURECLICK 89ENDARI 73ENDOCET 1ENGERIX-B ADULT 53ENGERIX-B PEDIATRIC-ADOLESCENT 53enoxaparin sodium 15ENPRESSE 79ENSKYCE 79ENSPRYNG 92
entacapone 46entecavir 57ENTRESTO 98ENULOSE 69EPCLUSA 75EPIDIOLEX 16epinastine hcl 71epinephrine 0.15 mg auto-injct (teva) 104epinephrine 0.15 mg auto-inject (generic for epi-pen jr / mylan) 104epinephrine 0.3 mg auto-inject (generic foradrenaclick) 104epinephrine 0.3 mg auto-inject (generic for epi-pen / mylan) 104epinephrine 0.3 mg auto-inject (teva) 104EPIVIR HBV 50eplerenone 99epoprostenol sodium 100ergoloid mesylates 1ERIVEDGE 34ERLEADA 34erlotinib hcl 34ERRIN 79erythromycin 7,8erythromycin-benzoyl peroxide 8ESBRIET 99escitalopram oxalate 19esomeprazole magnesium 56ESPEROCT 25ESTARYLLA 79estradiol 70estradiol (once weekly) 70estradiol (twice weekly) 70estradiol-norethindrone acetat 70eszopiclone 57ethambutol hcl 30ethosuximide 18ethynodiol-ethinyl estradiol 79etidronate disodium 87etodolac 96etodolac er 96
etonogestrel-ethinyl estradiol 79etoposide 34etravirine 49EUCRISA 10euthyrox 104everolimus 35EVOTAZ 50EVRYSDI 94exemestane 35ezetimibe 28
FFALMINA 79famciclovir 57famotidine 56FANAPT 47FASENRA PEN 9febuxostat 87FEIBA NF 25felbamate 16felodipine er 63FEMYNOR 79fenofibrate 28fentanyl 1FERRIPROX 75FERRIPROX (2 TIMES A DAY) 75FERRIPROX (3 TIMES A DAY) 76FETZIMA 18finasteride 87FINTEPLA 16FIRAZYR 88flecainide acetate 11FLOLAN 100FLOVENT DISKUS 67FLOVENT HFA 67FLUAD 2019-2020 53FLUAD 2020-2021 53FLUAD QUAD 2020-2021 53FLUAD QUAD 2021-2022 53FLUARIX QUAD 2019-2020 53FLUARIX QUAD 2020-2021 53
FLUARIX QUAD 2021-2022 53FLUBLOK QUAD 2019-2020 53FLUBLOK QUAD 2020-2021 53FLUBLOK QUAD 2021-2022 53FLUCELVAX QUAD 2019-2020 53FLUCELVAX QUAD 2020-2021 53FLUCELVAX QUAD 2021-2022 53fluconazole 22,23fludrocortisone acetate 76FLULAVAL QUAD 2019-2020 53FLULAVAL QUAD 2020-2021 53FLULAVAL QUAD 2021-2022 53FLUMIST QUAD 2019-2020 53FLUMIST QUAD 2020-2021 53FLUMIST QUAD 2021-2022 53flunisolide 9fluocinolone acetonide 10fluocinolone acetonide oil 9fluocinonide 10fluocinonide-e 11fluoride 87fluoritab 87fluorometholone 9fluorouracil 35fluoxetine hcl 19fluphenazine hcl 48flura-drops 87flurbiprofen 96flurbiprofen sodium 9flutamide 35fluticasone propionate 9,11fluticasone-salmeterol 113-14 (generic for airduorespiclick) 67fluticasone-salmeterol 232-14 (generic for airduorespiclick) 67fluticasone-salmeterol 55-14 (generic for airduorespiclick) 67fluvoxamine maleate 19FLUZONE HIGH-DOSE 2019-2020 53FLUZONE HIGH-DOSE QUAD 2020-21 53FLUZONE HIGH-DOSE QUAD 2021-22 53
FLUZONE QUAD 2019-2020 54FLUZONE QUAD 2020-2021 54FLUZONE QUAD 2021-2022 54FLUZONE QUAD PEDI 2019-2020 54FLUZONE QUAD SOUTHERN HEM 2020 54FLUZONE QUAD SOUTHERN HEM 2021 54FML S.O.P. 9folic acid 106fondaparinux sodium 14FORTEO 97fosamprenavir calcium 50fosfomycin tromethamine 6fosinopril sodium 98fosinopril-hydrochlorothiazide 98FOTIVDA 35FULPHILA 61furosemide 68FUZEON 49FYAVOLV 70FYCOMPA 16
Ggabapentin 16GALAFOLD 94galantamine er 60galantamine hbr 60galantamine hydrobromide 60GARDASIL 9 54GAVILYTE-C 73GAVILYTE-G 73GAVILYTE-N 73GAVRETO 35gemfibrozil 28GENERLAC 69GENGRAF 94gentamicin sulfate 8GENVOYA 50GIANVI 79GILENYA 92GILOTRIF 35GIMOTI 74
glatiramer acetate 92GLATOPA 92GLEOSTINE 35glimepiride 21glipizide 21glipizide er 21glipizide xl 21glipizide-metformin 21glucagon 1 mg emergency kit 27glucagon 1 mg emergency kit (genericglucagen) 27glucagon 1 mg emergency kit (Lilly) 27GLUCAGON 1 MG VIAL 27glyburide 21glyburide micronized 21glyburide-metformin hcl 21glycopyrrolate 14GLYXAMBI 21GRANIX 61GRASTEK 51griseofulvin 22griseofulvin ultramicrosize 22guaifenesin-codeine 99guanfacine hcl 84guanfacine hcl er 65GVOKE HYPOPEN 1-PACK 27GVOKE HYPOPEN 2-PACK 27GVOKE PFS 1-PACK SYRINGE 27GVOKE PFS 2-PACK SYRINGE 27
HHAEGARDA 88HAILEY 79HAILEY FE 79haloperidol 48haloperidol lactate 48HARVONI 75HAVRIX 54HEATHER 79HELIXATE FS 25HEMLIBRA 25
HEMOFIL M 25heparin sodium 15HEPLISAV-B 54HIBERIX 54homatropaire 71homatropine hydrobromide 71HUMALOG 85HUMALOG JUNIOR KWIKPEN 85HUMALOG KWIKPEN U-100 85HUMALOG KWIKPEN U-200 85HUMALOG MIX 50-50 85HUMALOG MIX 50-50 KWIKPEN 85HUMALOG MIX 75-25 85HUMALOG MIX 75-25 KWIKPEN 85HUMATE-P 25HUMIRA 89HUMIRA PEN 89HUMIRA PEN CROHN'S-UC-HS 90HUMIRA PEN PSOR-UVEITS-ADOL HS 90HUMIRA(CF) 90HUMIRA(CF) PEDIATRIC CROHN'S 73,90HUMIRA(CF) PEN 90HUMIRA(CF) PEN CROHN'S-UC-HS 90HUMIRA(CF) PEN PEDIATRIC UC 90HUMIRA(CF) PEN PSOR-UV-ADOL HS 90HUMULIN 70-30 85HUMULIN 70/30 KWIKPEN 85HUMULIN N 85HUMULIN N KWIKPEN 85HUMULIN R 86HUMULIN R U-500 86HUMULIN R U-500 KWIKPEN 86HYCAMTIN 35hydralazine hcl 84hydrochlorothiazide 68hydrocodone-acetaminophen 1,2hydrocodone-ibuprofen 2hydrocortisone 11,76hydrocortisone acetate 11hydrocortisone butyrate 11hydrocortisone valerate 11
hydrocortisone-iodoquinol 8hydrocortisone-pramoxine 11hydromorphone hcl 2hydroxychloroquine sulfate 46hydroxyprogesterone caproate 84hydroxyurea 35hydroxyzine hcl 58hydroxyzine pamoate 58hyoscyamine sulfate 14hyoscyamine sulfate er 14hyoscyamine sulfate sr 14hyosyne 14
Iibandronate sodium 87IBRANCE 35ibuprofen 96ICLEVIA 79ICLUSIG 35,36icosapent ethyl 28IDELVION 26IDHIFA 36ILARIS 94imatinib mesylate 36IMBRUVICA 36imipramine hcl 19imiquimod 102INBRIJA 46INCASSIA 79INCRUSE ELLIPTA 14indapamide 68indomethacin 96INFANRIX DTAP 52INGREZZA 66INGREZZA INITIATION PACK 66INLYTA 36INQOVI 37INREBIC 37insulin lispro 86insulin lispro junior kwikpen 86insulin lispro kwikpen u-100 86
insulin lispro protamine mix 86INTELENCE 49INTRON A 56INTROVALE 79INVIRASE 51INVOKAMET 21INVOKAMET XR 21INVOKANA 21IPOL 54ipratropium bromide 14,71ipratropium-albuterol 14irbesartan 98irbesartan-hydrochlorothiazide 98IRESSA 37ISENTRESS 49ISENTRESS HD 49ISIBLOOM 79isoniazid 30isosorbide dinitrate 105isosorbide mononitrate 105isosorbide mononitrate er 105isotretinoin 102ISTURISA 94itraconazole 23ivermectin 6IXINITY 26
JJAIMIESS 80JAKAFI 37JANSSEN COVID-19 VACCINE (EUA) 54jantoven 14JARDIANCE 21JASMIEL 80JENCYCLA 80JENTADUETO 20JENTADUETO XR 20JINTELI 70JIVI 26JOLESSA 80JULEBER 80
JULUCA 49JUNEL 80JUNEL FE 80JUXTAPID 28
KKALBITOR 88KALETRA 51KALLIGA 80KALYDECO 68KARIVA 80KELNOR 1-35 80KELNOR 1-50 80KESIMPTA PEN 92ketoconazole 23ketorolac tromethamine 9,96KINERET 90KINRIX 54KISQALI 37KISQALI FEMARA CO-PACK 37,38KLOR-CON M10 69KLOR-CON M15 69KLOR-CON M20 69KLOXXADO 65KOATE 26KOGENATE FS 26KOSELUGO 38KOVALTRY 26KURVELO 80
Llabetalol hcl 64lactulose 69lamivudine 50lamivudine hbv 50lamivudine-zidovudine 50lamotrigine 16LAMPIT 47lansoprazole 56LANTUS 85LANTUS SOLOSTAR 85
lapatinib 38LARIN 80LARIN FE 80LARISSIA 80latanoprost 24LATUDA 47ledipasvir-sofosbuvir 75LEENA 80leflunomide 91LESSINA 80letrozole 38leucovorin calcium 87LEUKERAN 38levalbuterol tartrate hfa 61LEVEMIR 85LEVEMIR FLEXTOUCH 85levetiracetam 16levetiracetam er 16levobunolol hcl 24levocarnitine 69,95levocarnitine sf 95levofloxacin 12LEVONEST 80levonorg-eth estrad eth estrad 80levonorgestrel 80levonorgestrel-eth estradiol 80LEVORA-28 80levothyroxine sodium 104LEXIVA 51lidocaine hcl 71lidocaine hcl viscous 71lidocaine-prilocaine 101LILLOW 80linezolid 13LINZESS 73liothyronine sodium 104lisinopril 98lisinopril-hydrochlorothiazide 98lithium 65lithium carbonate 65lithium carbonate er 65
LO-ZUMANDIMINE 81LOJAIMIESS 81LOMAIRA 4LONSURF 38lopinavir-ritonavir 51LOPREEZA 70lorazepam 59LORAZEPAM INTENSOL 59LORBRENA 38,39LORCET 2LORCET HD 2LORCET PLUS 2LORYNA 81losartan potassium 98losartan-hydrochlorothiazide 98loteprednol etabonate 9lovastatin 28LOW-OGESTREL 81loxapine 47lubiprostone 73ludent fluoride 88LUMAKRAS 39LUMIGAN 24LUTERA 81LYNPARZA 39LYSODREN 39LYZA 81
MM-M-R II VACCINE 54m-natal plus 105MAKENA 84malathion 8MARLISSA 81MATULANE 39MATZIM LA 62MAVENCLAD 94MAVYRET 75MAYZENT 92,93MEDROL 76medroxyprogesterone acetate 84
mefloquine hcl 46megestrol acetate 84MEKINIST 39MEKTOVI 39meloxicam 96melphalan 39memantine hcl 65MENACTRA 54MENQUADFI 54MENVEO A-C-Y-W-135-DIP 54MENVEO MENA COMPONENT 54MENVEO MENCYW-135 COMPONENT 54mercaptopurine 39mesalamine 72mesalamine dr 72mesalamine er 72METADATE ER 5metformin hcl 20metformin hcl 1,000 mg tablet (generic forglucophage) 20metformin hcl 500 mg tablet (generic forglucophage) 20metformin hcl er 20methadone hcl 2METHADONE INTENSOL 2METHADOSE 2methazolamide 24methimazole 104methocarbamol 101methotrexate 40methotrexate sodium 40methyldopa 84methylergonovine maleate 96methylphenidate er 5methylphenidate er (la) 5methylphenidate hcl 5methylphenidate hcl cd 5methylphenidate hcl er (cd) 5methylphenidate la 5methylprednisolone 76methyltestosterone 77
metoclopramide hcl 74metoclopramide hcl odt 74metolazone 68metoprolol succinate 64metoprolol tartrate 64metoprolol-hydrochlorothiazide 64metronidazole 8,47mexiletine hcl 11MICROGESTIN 81MICROGESTIN FE 81midodrine hcl 104miglitol 20miglustat 95MILI 81MILLIPRED 76MIMVEY LO 70minocycline hcl 13minoxidil 84mirtazapine 18misoprostol 56modafinil 6MODERNA COVID-19 VACCINE (EUA) 54moexipril hcl 98mometasone furoate 11MONDOXYNE NL 13MONO-LINYAH 81MONONINE 26montelukast sodium 10morphine sulfate 2morphine sulfate er 2MORPHINE SULFATE IR 15 MG TAB (BRAND) 2MORPHINE SULFATE IR 30 MG TAB (BRAND) 2MOVANTIK 73moxifloxacin 7moxifloxacin hcl 12MULTAQ 12mupirocin 8MY WAY 81mycophenolate mofetil 94mycophenolic acid 94MYFEMBREE 74
MYLERAN 40mynatal plus 105mynatal-z 105MYORISAN 102MYRBETRIQ 61
Nnabumetone 96nadolol 64naloxone hcl 65naltrexone hcl 65naproxen 96naratriptan hcl 30NARCAN 65nateglinide 21NAYZILAM 18NECON 81nefazodone hcl 19neomycin sulfate 12neomycin-bacitracin-polymyxin 7neomycin-polymyxin-dexameth 7neomycin-polymyxin-gramicidin 7neomycin-polymyxin-hc 7neomycin-polymyxin-hydrocort 7NERLYNX 40NEUPRO 69nevirapine 49nevirapine er 49NEXAVAR 40nicotine gum 59nicotine lozenge 59nicotine patch 60NICOTROL 60NICOTROL NS 60nifedipine 63nifedipine er 63NIKKI 81nimodipine 63NINLARO 40nitazoxanide 47NITRO-BID 105
nitrofurantoin 6nitrofurantoin mono-macro 6nitroglycerin 105nitroglycerin patch 105NORA-BE 81norethindron-ethinyl estradiol 71,81norethindrone 81norethindrone ac (lupaneta) 84norethindrone acetate 84norethindrone-e.estradiol-iron 81norgestimate-ethinyl estradiol 81NORLYDA 81NORPACE CR 11NORTREL 81nortriptyline hcl 19NORVIR 51NOURIANZ 65NOVAVAX COVID19 VAC,ADJ(UNAPP) 54NOVOEIGHT 26novolin 70-30 flexpen 85NOVOSEVEN RT 26NUBEQA 40NUCALA 10NUPLAZID 47NURTEC ODT 29NUWIQ 26NUZYRA 104NYMYO 81nystatin 23NYVEPRIA 61
OO-CAL PRENATAL 105OBIZUR 26OCELLA 81octreotide acetate 103ODACTRA 51ODEFSEY 50ODOMZO 40OFEV 99ofloxacin 7
OGESTREL 82olanzapine 47olanzapine odt 48olmesartan medoxomil 98olmesartan-hydrochlorothiazide 98olopatadine hcl 71OLUMIANT 91omega-3 acid ethyl esters 28omeprazole 56ondansetron hcl 22ondansetron odt 22ONUREG 40OPSUMIT 100ORENCIA 91ORENCIA CLICKJECT 91ORGOVYX 74ORIAHNN 74ORILISSA 74ORKAMBI 68ORLADEYO 88ORSYTHIA 82oscimin 14oscimin sl 14oscimin sr 14oseltamivir phosphate 57OTEZLA 91oxandrolone 77OXBRYTA 61oxcarbazepine 16OXERVATE 71oxybutynin chloride 74oxybutynin chloride er 74oxycodone hcl 3oxycodone hcl er 3oxycodone hcl-aspirin 3oxycodone-acetaminophen 3OXYCONTIN 3OZEMPIC 20
PPACERONE 12
PALFORZIA 51paliperidone er 48pantoprazole sodium 56paregoric 72PAROEX 7paroxetine hcl 19PAXIL 19PEDIARIX 54PEDVAXHIB 54peg 3350-electrolyte 73PEGASYS 57PEGASYS PROCLICK 57PEGINTRON 57PEMAZYRE 40penicillamine 76penicillin v potassium 97PENTACEL 54PENTACEL ACTHIB COMPONENT 54PENTACEL DTAP-IPV COMPONENT 54pentoxifylline 62perindopril erbumine 98PERIOGARD 7permethrin 8perphenazine 49PFIZER COVID-19 VACCINE (EUA) 55PHENADOZ 72phenazopyridine hcl 101phenelzine sulfate 18phenobarbital 58phenoxybenzamine hcl 1phentermine hcl 4phenylephrine hcl 72phenytoin 18phenytoin sodium extended 18PHILITH 82PHOSLYRA 86phytonadione 106PICATO 41pilocarpine hcl 24,60pimecrolimus 102PIMTREA 82
pioglitazone hcl 22pioglitazone-glimepiride 22pioglitazone-metformin 22PIRMELLA 82piroxicam 96PLEGRIDY 93PLEGRIDY PEN 93PNEUMOVAX 23 55pnv 29-1 105podofilox 102polymyxin b sul-trimethoprim 7POMALYST 41PORTIA 82posaconazole 23potassium chloride 69potassium citrate er 69PRADAXA 15pramipexole dihydrochloride 69prasugrel hcl 51pravastatin sodium 28praziquantel 6prazosin hcl 64prednisolone 76prednisolone ac 1% eye drop (generic predforte) 9prednisolone sodium phosphate 9,76prednisone 76PREDNISONE INTENSOL 76pregabalin 16,17PREMARIN 71PREMPRO 71PRENATA 105PRENATABS FA 105PRENATABS RX 106prenatal plus 106prenatal vitamin plus low iron 106prenatal-u 106PRENATE ELITE 106preplus 106pretomanid 30PREVALITE 28
PREVIFEM 82PREVNAR 13 55PREVNAR 20 55PREVYMIS 56PREZCOBIX 51PREZISTA 51PRIFTIN 30primidone 17probenecid 69probenecid-colchicine 69prochlorperazine 22prochlorperazine maleate 22PROCTO-MED HC 11PROCTOSOL-HC 11PROCTOZONE-HC 11PROFILNINE 26progesterone 84PROMACTA 61promethazine hcl 72promethazine vc 72promethazine-dm 99promethazine-phenylephrine 72PROMETHEGAN 72propafenone hcl 11propantheline bromide 14propranolol hcl 64propranolol hcl er 64propranolol-hydrochlorothiazid 64propylthiouracil 104PROQUAD 55PULMICORT FLEXHALER 67PULMOZYME 99PUREFE OB PLUS 106pyrazinamide 30pyridostigmine bromide 60pyridostigmine bromide er 60
QQINLOCK 41QUADRACEL DTAP-IPV 55quetiapine fumarate 48
quetiapine fumarate er 48QUILLICHEW ER 5QUILLIVANT XR 5quinapril hcl 98quinapril-hydrochlorothiazide 99quinidine sulfate 11QVAR REDIHALER 67
Rrabeprazole sodium 56RAGWITEK 52raloxifene hcl 70ramelteon 58ramipril 99rasagiline mesylate 46RASUVO 41REBIF 93REBIF REBIDOSE 93REBINYN 26RECLIPSEN 82RECOMBINATE 26RECOMBIVAX HB 55REDITREX 93RELENZA 57relion novolin 70-30 vial 85relion novolin n 100 unit/ml 85relion novolin n u-100 flexpen 85relion novolin r 100 unit/ml 86relion novolin r u-100 flexpen 86repaglinide 21REPATHA PUSHTRONEX 29REPATHA SURECLICK 29REPATHA SYRINGE 29RESTASIS 9RESTASIS MULTIDOSE 9RETACRIT 62RETEVMO 41REVCOVI 70REVLIMID 41REXULTI 48REYATAZ 51
REYVOW 30REZUROCK 95RHOPRESSA 24ribavirin 57RIDAURA 74rifabutin 30rifampin 30riluzole 65rimantadine hcl 56RINVOQ 91risperidone 48risperidone odt 48ritonavir 51rivastigmine 60RIXUBIS 26rizatriptan 30ROCKLATAN 24ropinirole hcl 69ROSADAN 8rosuvastatin calcium 28ROTARIX 55ROTATEQ 55ROZLYTREK 41RUCONEST 88rufinamide 17RUKOBIA 49RUZURGI 95RYBELSUS 20RYDAPT 41RYTARY 46
Ssalsalate 96SANDOSTATIN LAR DEPOT 103,104sapropterin dihydrochloride 95scopolamine 22se-natal 19 106SECUADO 48selegiline hcl 46selenium sulfide 8SELZENTRY 49
SENSIPAR 97SEREVENT DISKUS 61sertraline hcl 19SETLAKIN 82sevelamer carbonate 86SEVENFACT 27sf 88sf 5000 plus 88SHAROBEL 82SHINGRIX 55SHINGRIX ADJUVANT COMPONENT 97SHINGRIX GE ANTIGEN COMPONENT 55SIGNIFOR 104sildenafil 20 mg tablet (generic for revatio) 105silver sulfadiazine 8SIMLIYA 82SIMPESSE 82simvastatin 29sirolimus 94SIRTURO 30SIVEXTRO 13SKYRIZI 102SKYRIZI (2 SYRINGES) KIT 102SKYRIZI PEN 103sodium fluoride 88sodium phenylbutyrate 69sodium polystyrene sulfonate 86sodium sulfacetamide-sulfur 8,101sofosbuvir-velpatasvir 75solifenacin succinate 74SOLIQUA 100-33 85SOLTAMOX 70SOLU-CORTEF 76sotalol 64SOTALOL AF 64SOVALDI 75spironolactone 99spironolactone-hctz 99SPRINTEC 82SPRYCEL 41SRONYX 82
SSD 8sss 10-5 101STIMATE 84STIVARGA 42STRENSIQ 70STRIBILD 50STRIVERDI RESPIMAT 61SUBVENITE 17SUCRAID 70sucralfate 56sulfacetamide sodium 7,8sulfacetamide-prednisolone 7sulfamethoxazole-trimethoprim 12sulfasalazine 12sulfasalazine dr 12SULFATRIM 12sulindac 96sumatriptan 30sumatriptan succinate 30sunitinib malate 42SUNOSI 6SUPREP 73SYEDA 82SYLATRON 57symax-sr 14SYMDEKO 67SYMJEPI 104SYMPROIC 73SYMTUZA 51SYNJARDY 21SYNJARDY XR 21SYNTHROID 104
TTABLOID 42TABRECTA 42tacrolimus 94,103tadalafil 105tadalafil 20 mg tablet (generic for adcirca) 105TAFINLAR 42TAGRISSO 42
TAKHZYRO 88TALICIA 55tamoxifen citrate 70tamsulosin hcl 1TARINA 24 FE 82TARINA FE 82TARINA FE 1-20 EQ 82TASIGNA 42tazarotene 103TAZTIA XT 62TAZVERIK 42tdvax 52telmisartan 98telmisartan-hydrochlorothiazid 98temazepam 59temozolomide 42TENCON 1TENIVAC 52tenofovir disoproxil fumarate 50TEPMETKO 43terazosin hcl 64terbinafine hcl 22terconazole 23teriparatide 97testosterone 77testosterone cypionate 77testosterone enanthate 77testosterone propionate 77tetrabenazine 66THALOMID 93theophylline 103theophylline anhydrous 103THIOLA 95THIOLA EC 95thioridazine hcl 49thiothixene 49TIADYLT ER 62tiagabine hcl 17TIBSOVO 43TILIA FE 82timolol maleate 24,64
timolol maleate 0.25% eye drop (generic fortimoptic) 24timolol maleate 0.5% eye drops (generic fortimoptic) 24tiopronin 95TIVICAY 49TIVICAY PD 49tizanidine hcl 101TOBRADEX 7tobramycin 7,12tobramycin-dexamethasone 7TOBREX 7TODAY CONTRACEPTIVE SPONGE 95tolmetin sodium 96tolterodine tartrate 74tolterodine tartrate er 74topiramate 17torsemide 68TOUJEO MAX SOLOSTAR 85TOUJEO SOLOSTAR 85TPOXX (NATIONAL STOCKPILE) 56TRACLEER 100TRADJENTA 20tramadol hcl 3tramadol hcl-acetaminophen 3trandolapril 99tranexamic acid 27tranylcypromine sulfate 18travoprost 24trazodone hcl 19TRECATOR 31TRELEGY ELLIPTA 67treprostinil 100tretinoin 43,101TRETTEN 27TRI FEMYNOR 82TRI-ESTARYLLA 82TRI-LEGEST FE 82TRI-LINYAH 82TRI-LO-ESTARYLLA 82TRI-LO-MARZIA 83
TRI-LO-MILI 83TRI-LO-SPRINTEC 83TRI-MILI 83TRI-PREVIFEM 83TRI-SPRINTEC 83TRI-VYLIBRA 83TRI-VYLIBRA LO 83triamcinolone acetonide 11triamterene-hydrochlorothiazid 68TRIDERM 11trifluoperazine hcl 49trifluridine 7trihexyphenidyl hcl 46TRIJARDY XR 21TRIKAFTA 67TRIKLO 28TRILYTE WITH FLAVOR PACKETS 73trimethobenzamide hcl 22trimethoprim 6TRINATE 106TRINTELLIX 19TRIUMEQ 50TRIVORA-28 83trospium chloride 74TRULICITY 20TRUMENBA 55TRUSELTIQ 43TRUVADA 50TULANA 83TURALIO 43TWINRIX 55TYBLUME 83TYBOST 95TYMLOS 97TYVASO 100TYVASO REFILL KIT 100TYVASO STARTER KIT 100
UUDENYCA 62UKONIQ 43
UPTRAVI 100urea 101ursodiol 73
Vvalacyclovir 57VALCHLOR 43valganciclovir hcl 57valproic acid 17valsartan 98valsartan-hydrochlorothiazide 98VALTOCO 59vancomycin hcl 13VAQTA 55varenicline tartrate 60VARIVAX VACCINE 55VASCEPA 28VAXCHORA ACTIVE COMPONENT 55VAXCHORA BUFFER COMPONENT 97VAXCHORA VACCINE 55VAXELIS 52VAXNEUVANCE 55vcf 95VELIVET 83VEMLIDY 57venlafaxine hcl 19venlafaxine hcl er 19VENTAVIS 100VENTOLIN HFA 61verapamil er 62verapamil hcl 62verapamil sr 62VERQUVO 105VERSACLOZ 48VERZENIO 43VESTURA 83VICTOZA 2-PAK 20VICTOZA 3-PAK 21VIENVA 83vigabatrin 17VIGADRONE 17
VIIBRYD 19VIMPAT 17VINATE CARE 106vinate one 106vinate-m 106VIORELE 83VIREAD 50VISTOGARD 87vitamin d2 106VITRAKVI 43,44VIVOTIF 55VIZIMPRO 44VOCABRIA 49VOLNEA 83VONVENDI 27voriconazole 23VOSEVI 75VOTRIENT 44VRAYLAR 48VUMERITY 93VYFEMLA 83VYLIBRA 83VYNDAMAX 63VYNDAQEL 63VYVANSE 4
WWAKIX 6warfarin sodium 14WELIREG 44WERA 83WILATE 27
XXALKORI 44XARELTO 14XENICAL 73XENLETA 13XERMELO 72XIFAXAN 13XOSPATA 44
XPOVIO 44XTANDI 45XULANE 83XULTOPHY 100-3.6 85XYNTHA 27XYNTHA SOLOFUSE 27XYREM 65XYWAV 65
YYUVAFEM 71
Zzaleplon 58ZARAH 83ZEBUTAL 1ZEGALOGUE AUTOINJECTOR 27ZEGALOGUE SYRINGE 27ZEJULA 45ZELBORAF 45ZENATANE 103ZENZEDI 4ZEPOSIA 93zidovudine 50ZIEXTENZO 62ZIOPTAN 24ziprasidone hcl 48ZIRGAN 7ZOKINVY 95ZOLINZA 45zolmitriptan 30zolmitriptan odt 30zolpidem tartrate 58zonisamide 17ZONTIVITY 51ZOSTAVAX 55ZOVIA 1-35 83ZOVIA 1-35E 83ZUMANDIMINE 83ZYKADIA 45
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